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STRESS AND HEALTH: Psychological, Behavioral, and Biological Determinants

Stressors have a major influence upon mood, our sense of well-being, behavior, and health. Acute stress responses in young, healthy individuals may be adaptive and typically do not impose a health burden. However, if the threat is unremitting, particularly in older or unhealthy individuals, the long-term effects of stressors can damage health. The relationship between psychosocial stressors and disease is affected by the nature, number, and persistence of the stressors as well as by the individual’s biological vulnerability (i.e., genetics, constitutional factors), psychosocial resources, and learned patterns of coping. Psychosocial interventions have proven useful for treating stress-related disorders and may influence the course of chronic diseases.

INTRODUCTION

Claude Bernard (1865/1961) noted that the maintenance of life is critically dependent on keeping our internal milieu constant in the face of a changing environment. Cannon (1929) called this “homeostasis.” Selye (1956) used the term “stress” to represent the effects of anything that seriously threatens homeostasis. The actual or perceived threat to an organism is referred to as the “stressor” and the response to the stressor is called the “stress response.” Although stress responses evolved as adaptive processes, Selye observed that severe, prolonged stress responses might lead to tissue damage and disease.

Based on the appraisal of perceived threat, humans and other animals invoke coping responses ( Lazarus & Folkman 1984 ). Our central nervous system (CNS) tends to produce integrated coping responses rather than single, isolated response changes ( Hilton 1975 ). Thus, when immediate fight-or-flight appears feasible, mammals tend to show increased autonomic and hormonal activities that maximize the possibilities for muscular exertion ( Cannon 1929 , Hess 1957 ). In contrast, during aversive situations in which an active coping response is not available, mammals may engage in a vigilance response that involves sympathetic nervous system (SNS) arousal accompanied by an active inhibition of movement and shunting of blood away from the periphery ( Adams et al. 1968 ). The extent to which various situations elicit different patterns of biologic response is called “situational stereotypy” ( Lacey 1967 ).

Although various situations tend to elicit different patterns of stress responses, there are also individual differences in stress responses to the same situation. This tendency to exhibit a particular pattern of stress responses across a variety of stressors is referred to as “response stereotypy” ( Lacey & Lacey 1958 ). Across a variety of situations, some individuals tend to show stress responses associated with active coping, whereas others tend to show stress responses more associated with aversive vigilance ( Kasprowicz et al. 1990 , Llabre et al. 1998 ).

Although genetic inheritance undoubtedly plays a role in determining individual differences in response stereotypy, neonatal experiences in rats have been shown to produce long-term effects in cognitive-emotional responses ( Levine 1957 ). For example, Meaney et al. (1993) showed that rats raised by nurturing mothers have increased levels of central serotonin activity compared with rats raised by less nurturing mothers. The increased serotonin activity leads to increased expression of a central glucocorticoid receptor gene. This, in turn, leads to higher numbers of glucocorticoid receptors in the limbic system and improved glucocorticoid feedback into the CNS throughout the rat’s life. Interestingly, female rats who receive a high level of nurturing in turn become highly nurturing mothers whose offspring also have high levels of glucocorticoid receptors. This example of behaviorally induced gene expression shows how highly nurtured rats develop into low-anxiety adults, who in turn become nurturing mothers with reduced stress responses.

In contrast to highly nurtured rats, pups separated from their mothers for several hours per day during early life have a highly active hypothalamic-pituitary adrenocortical axis and elevated SNS arousal ( Ladd et al. 2000 ). These deprived rats tend to show larger and more frequent stress responses to the environment than do less deprived animals.

Because evolution has provided mammals with reasonably effective homeostatic mechanisms (e.g., baroreceptor reflex) for dealing with short-term stressors, acute stress responses in young, healthy individuals typically do not impose a health burden. However, if the threat is persistent, particularly in older or unhealthy individuals, the long-term effects of the response to stress may damage health ( Schneiderman 1983 ). Adverse effects of chronic stressors are particularly common in humans, possibly because their high capacity for symbolic thought may elicit persistent stress responses to a broad range of adverse living and working conditions. The relationship between psychosocial stressors and chronic disease is complex. It is affected, for example, by the nature, number, and persistence of the stressors as well as by the individual’s biological vulnerability (i.e., genetics, constitutional factors) and learned patterns of coping. In this review, we focus on some of the psychological, behavioral, and biological effects of specific stressors, the mediating psychophysiological pathways, and the variables known to mediate these relationships. We conclude with a consideration of treatment implications.

PSYCHOLOGICAL ASPECTS OF STRESS

Stressors during childhood and adolescence and their psychological sequelae.

The most widely studied stressors in children and adolescents are exposure to violence, abuse (sexual, physical, emotional, or neglect), and divorce/marital conflict (see Cicchetti 2005 ). McMahon et al. (2003) also provide an excellent review of the psychological consequences of such stressors. Psychological effects of maltreatment/abuse include the dysregulation of affect, provocative behaviors, the avoidance of intimacy, and disturbances in attachment ( Haviland et al. 1995 , Lowenthal 1998 ). Survivors of childhood sexual abuse have higher levels of both general distress and major psychological disturbances including personality disorders ( Polusny & Follett 1995 ). Childhood abuse is also associated with negative views toward learning and poor school performance ( Lowenthal 1998 ). Children of divorced parents have more reported antisocial behavior, anxiety, and depression than their peers ( Short 2002 ). Adult offspring of divorced parents report more current life stress, family conflict, and lack of friend support compared with those whose parents did not divorce ( Short 2002 ). Exposure to nonresponsive environments has also been described as a stressor leading to learned helplessness ( Peterson & Seligman 1984 ).

Studies have also addressed the psychological consequences of exposure to war and terrorism during childhood ( Shaw 2003 ). A majority of children exposed to war experience significant psychological morbidity, including both post-traumatic stress disorder (PTSD) and depressive symptoms. For example, Nader et al. (1993) found that 70% of Kuwaiti children reported mild to severe PTSD symptoms after the Gulf War. Some effects are long lasting: Macksound & Aber (1996) found that 43% of Lebanese children continued to manifest post-traumatic stress symptoms 10 years after exposure to war-related trauma.

Exposure to intense and chronic stressors during the developmental years has long-lasting neurobiological effects and puts one at increased risk for anxiety and mood disorders, aggressive dyscontrol problems, hypo-immune dysfunction, medical morbidity, structural changes in the CNS, and early death ( Shaw 2003 ).

Stressors During Adulthood and Their Psychological Sequelae

Life stress, anxiety, and depression.

It is well known that first depressive episodes often develop following the occurrence of a major negative life event ( Paykel 2001 ). Furthermore, there is evidence that stressful life events are causal for the onset of depression (see Hammen 2005 , Kendler et al. 1999 ). A study of 13,006 patients in Denmark, with first psychiatric admissions diagnosed with depression, found more recent divorces, unemployment, and suicides by relatives compared with age- and gender-matched controls ( Kessing et al. 2003 ). The diagnosis of a major medical illness often has been considered a severe life stressor and often is accompanied by high rates of depression ( Cassem 1995 ). For example, a meta-analysis found that 24% of cancer patients are diagnosed with major depression ( McDaniel et al. 1995 ).

Stressful life events often precede anxiety disorders as well ( Faravelli & Pallanti 1989 , Finlay-Jones & Brown 1981 ). Interestingly, long-term follow-up studies have shown that anxiety occurs more commonly before depression ( Angst &Vollrath 1991 , Breslau et al. 1995 ). In fact, in prospective studies, patients with anxiety are most likely to develop major depression after stressful life events occur ( Brown et al. 1986 ).

DISORDERS RELATED TO TRAUMA

Lifetime exposure to traumatic events in the general population is high, with estimates ranging from 40% to 70% ( Norris 1992 ). Of note, an estimated 13% of adult women in the United States have been exposed to sexual assault ( Kilpatrick et al. 1992 ). The Diagnostic and Statistical Manual (DSM-IV-TR; American Psychiatric Association 2000 ) includes two primary diagnoses related to trauma: Acute Stress Disorder (ASD) and PTSD. Both these disorders have as prominent features a traumatic event involving actual or threatened death or serious injury and symptom clusters including re-experiencing of the traumatic event (e.g., intrusive thoughts), avoidance of reminders/numbing, and hyperarousal (e.g., difficulty falling or staying asleep). The time frame for ASD is shorter (lasting two days to four weeks), with diagnosis limited to within one month of the incident. ASD was introduced in 1994 to describe initial trauma reactions, but it has come under criticism ( Harvey & Bryant 2002 ) for weak empirical and theoretical support. Most people who have symptoms of PTSD shortly after a traumatic event recover and do not develop PTSD. In a comprehensive review, Green (1994) estimates that approximately 25% of those exposed to traumatic events develop PTSD. Surveys of the general population indicate that PTSD affects 1 in 12 adults at some time in their life ( Kessler et al. 1995 ). Trauma and disasters are related not only to PTSD, but also to concurrent depression, other anxiety disorders, cognitive impairment, and substance abuse ( David et al. 1996 , Schnurr et al. 2002 , Shalev 2001 ).

Other consequences of stress that could provide linkages to health have been identified, such as increases in smoking, substance use, accidents, sleep problems, and eating disorders. Populations that live in more stressful environments (communities with higher divorce rates, business failures, natural disasters, etc.) smoke more heavily and experience higher mortality from lung cancer and chronic obstructive pulmonary disorder ( Colby et al. 1994 ). A longitudinal study following seamen in a naval training center found that more cigarette smoking occurred on high-stress days ( Conway et al. 1981 ). Life events stress and chronically stressful conditions have also been linked to higher consumption of alcohol ( Linsky et al. 1985 ). In addition, the possibility that alcohol may be used as self-medication for stress-related disorders such as anxiety has been proposed. For example, a prospective community study of 3021 adolescents and young adults ( Zimmerman et al. 2003 ) found that those with certain anxiety disorders (social phobia and panic attacks) were more likely to develop substance abuse or dependence prospectively over four years of follow-up. Life in stressful environments has also been linked to fatal accidents ( Linsky & Strauss 1986 ) and to the onset of bulimia ( Welch et al. 1997 ). Another variable related to stress that could provide a link to health is the increased sleep problems that have been reported after sychological trauma ( Harvey et al. 2003 ). New onset of sleep problems mediated the relationship between post-traumatic stress symptoms and decreased natural killer (NK) cell cytotoxicity in Hurricane Andrew victims ( Ironson et al. 1997 ).

Variations in Stress Responses

Certain characteristics of a situation are associated with greater stress responses. These include the intensity or severity of the stressor and controllability of the stressor, as well as features that determine the nature of the cognitive responses or appraisals. Life event dimensions of loss, humiliation, and danger are related to the development of major depression and generalized anxiety ( Kendler et al. 2003 ). Factors associated with the development of symptoms of PTSD and mental health disorders include injury, damage to property, loss of resources, bereavement, and perceived life threat ( Freedy et al. 1992 , Ironson et al. 1997 , McNally 2003 ). Recovery from a stressor can also be affected by secondary traumatization ( Pfefferbaum et al. 2003 ). Other studies have found that multiple facets of stress that may work synergistically are more potent than a single facet; for example, in the area of work stress, time pressure in combination with threat ( Stanton et al. 2001 ), or high demand in combination with low control ( Karasek & Theorell 1990 ).

Stress-related outcomes also vary according to personal and environmental factors. Personal risk factors for the development of depression, anxiety, or PTSD after a serious life event, disaster, or trauma include prior psychiatric history, neuroticism, female gender, and other sociodemographic variables ( Green 1996 , McNally 2003 , Patton et al. 2003 ). There is also some evidence that the relationship between personality and environmental adversity may be bidirectional ( Kendler et al. 2003 ). Levels of neuroticism, emotionality, and reactivity correlate with poor interpersonal relationships as well as “event proneness.” Protective factors that have been identified include, but are not limited to, coping, resources (e.g., social support, self-esteem, optimism), and finding meaning. For example, those with social support fare better after a natural disaster ( Madakaisira & O’Brien 1987 ) or after myocardial infarction ( Frasure-Smith et al. 2000 ). Pruessner et al. (1999) found that people with higher self-esteem performed better and had lower cortisol responses to acute stressors (difficult math problems). Attaching meaning to the event is another protective factor against the development of PTSD, even when horrific torture has occurred. Left-wing political activists who were tortured by Turkey’s military regime had lower rates of PTSD than did nonactivists who were arrested and tortured by the police ( Basoğlu et al. 1994 ).

Finally, human beings are resilient and in general are able to cope with adverse situations. A recent illustration is provided by a study of a nationally representative sample of Israelis after 19 months of ongoing exposure to the Palestinian intifada. Despite considerable distress, most Israelis reported adapting to the situation without substantial mental health symptoms or impairment ( Bleich et al. 2003 ).

BIOLOGICAL RESPONSES TO STRESSORS

Acute stress responses.

Following the perception of an acute stressful event, there is a cascade of changes in the nervous, cardiovascular, endocrine, and immune systems. These changes constitute the stress response and are generally adaptive, at least in the short term ( Selye 1956 ). Two features in particular make the stress response adaptive. First, stress hormones are released to make energy stores available for the body’s immediate use. Second, a new pattern of energy distribution emerges. Energy is diverted to the tissues that become more active during stress, primarily the skeletal muscles and the brain. Cells of the immune system are also activated and migrate to “battle stations” ( Dhabar & McEwen 1997 ). Less critical activities are suspended, such as digestion and the production of growth and gonadal hormones. Simply put, during times of acute crisis, eating, growth, and sexual activity may be a detriment to physical integrity and even survival.

Stress hormones are produced by the SNS and hypothalamic-pituitary adrenocortical axis. The SNS stimulates the adrenal medulla to produce catecholamines (e.g., epinephrine). In parallel, the paraventricular nucleus of the hypothalamus produces corticotropin releasing factor, which in turn stimulates the pituitary to produce adrenocorticotropin. Adrenocorticotropin then stimulates the adrenal cortex to secrete cortisol. Together, catecholamines and cortisol increase available sources of energy by promoting lipolysis and the conversion of glycogen into glucose (i.e., blood sugar). Lipolysis is the process of breaking down fats into usable sources of energy (i.e., fatty acids and glycerol; Brindley & Rollan 1989 ).

Energy is then distributed to the organs that need it most by increasing blood pressure levels and contracting certain blood vessels while dilating others. Blood pressure is increased with one of two hemodynamic mechanisms ( Llabre et al.1998 , Schneiderman & McCabe 1989 ). The myocardial mechanism increases blood pressure through enhanced cardiac output; that is, increases in heart rate and stroke volume (i.e., the amount of blood pumped with each heart beat). The vascular mechanism constricts the vasculature, thereby increasing blood pressure much like constricting a hose increases water pressure. Specific stressors tend to elicit either myocardial or vascular responses, providing evidence of situational stereotypy ( Saab et al. 1992 , 1993 ). Laboratory stressors that call for active coping strategies, such as giving a speech or performing mental arithmetic, require the participant to do something and are associated with myocardial responses. In contrast, laboratory stressors that call for more vigilant coping strategies in the absence of movement, such as viewing a distressing video or keeping one’s foot in a bucket of ice water, are associated with vascular responses. From an evolutionary perspective, cardiac responses are believed to facilitate active coping by shunting blood to skeletal muscles, consistent with the fight-or-flight response. In situations where decisive action would not be appropriate, but instead skeletal muscle inhibition and vigilance are called for, a vascular hemodynamic response is adaptive. The vascular response shunts blood away from the periphery to the internal organs, thereby minimizing potential bleeding in the case of physical assault.

Finally, in addition to the increased availability and redistribution of energy, the acute stress response includes activation of the immune system. Cells of the innate immune system (e.g., macrophages and natural killer cells), the first line of defense, depart from lymphatic tissue and spleen and enter the bloodstream, temporarily raising the number of immune cells in circulation (i.e., leukocytosis). From there, the immune cells migrate into tissues that are most likely to suffer damage during physical confrontation (e.g., the skin). Once at “battle stations,” these cells are in position to contain microbes that may enter the body through wounds and thereby facilitate healing ( Dhabar & McEwen 1997 ).

Chronic Stress Responses

The acute stress response can become maladaptive if it is repeatedly or continuously activated ( Selye 1956 ). For example, chronic SNS stimulation of the cardiovascular system due to stress leads to sustained increases in blood pressure and vascular hypertrophy ( Henry et al. 1975 ). That is, the muscles that constrict the vasculature thicken, producing elevated resting blood pressure and response stereotypy, or a tendency to respond to all types of stressors with a vascular response. Chronically elevated blood pressure forces the heart to work harder, which leads to hypertrophy of the left ventricle ( Brownley et al. 2000 ). Over time, the chronically elevated and rapidly shifting levels of blood pressure can lead to damaged arteries and plaque formation.

The elevated basal levels of stress hormones associated with chronic stress also suppress immunity by directly affecting cytokine profiles. Cytokines are communicatory molecules produced primarily by immune cells (see Roitt et al. 1998 ). There are three classes of cytokines. Proinflammatory cytokines mediate acute inflammatory reactions. Th1 cytokines mediate cellular immunity by stimulating natural killer cells and cytotoxic T cells, immune cells that target intracellular pathogens (e.g., viruses). Finally, Th2 cytokines mediate humoral immunity by stimulating B cells to produce antibody, which “tags” extracellular pathogens (e.g., bacteria) for removal. In a meta-analysis of over 30 years of research, Segerstrom & Miller (2004) found that intermediate stressors, such as academic examinations, could promote a Th2 shift (i.e., an increase in Th2 cytokines relative to Th1 cytokines). A Th2 shift has the effect of suppressing cellular immunity in favor of humoral immunity. In response to more chronic stressors (e.g., long-term caregiving for a dementia patient), Segerstrom & Miller found that proinflammatory, Th1, and Th2 cytokines become dysregulated and lead both to suppressed humoral and cellular immunity. Intermediate and chronic stressors are associated with slower wound healing and recovery from surgery, poorer antibody responses to vaccination, and antiviral deficits that are believed to contribute to increased vulnerability to viral infections (e.g., reductions in natural killer cell cytotoxicity; see Kiecolt-Glaser et al. 2002 ).

Chronic stress is particularly problematic for elderly people in light of immunosenescence, the gradual loss of immune function associated with aging. Older adults are less able to produce antibody responses to vaccinations or combat viral infections ( Ferguson et al. 1995 ), and there is also evidence of a Th2 shift ( Glaser et al. 2001 ). Although research has yet to link poor vaccination responses to early mortality, influenza and other infectious illnesses are a major cause of mortality in the elderly, even among those who have received vaccinations (e.g., Voordouw et al. 2003 ).

PSYCHOSOCIAL STRESSORS AND HEALTH

Cardiovascular disease.

Both epidemiological and controlled studies have demonstrated relationships between psychosocial stressors and disease. The underlying mediators, however, are unclear in most cases, although possible mechanisms have been explored in some experimental studies. An occupational gradient in coronary heart disease (CHD) risk has been documented in which men with relatively low socioeconomic status have the poorest health outcomes ( Marmot 2003 ). Much of the risk gradient in CHD can be eliminated, however, by taking into account lack of perceived job control, which is a potent stressor ( Marmot et al. 1997 ). Other factors include risky behaviors such as smoking, alcohol use, and sedentary lifestyle ( Lantz et al. 1998 ), which may be facilitated by stress. Among men ( Schnall et al. 1994 ) and women ( Eaker 1998 ), work stress has been reported to be a predictor of incident CHD and hypertension ( Ironson 1992 ). However, in women with existing CHD, marital stress is a better predictor of poor prognosis than is work stress ( Orth-Gomer et al. 2000 ).

Although the observational studies cited thus far reveal provocative associations between psychosocial stressors and disease, they are limited in what they can tell us about the exact contribution of these stressors or about how stress mediates disease processes. Animal models provide an important tool for helping to understand the specific influences of stressors on disease processes. This is especially true of atherosclerotic CHD, which takes multiple decades to develop in humans and is influenced by a great many constitutional, demographic, and environmental factors. It would also be unethical to induce disease in humans by experimental means.

Perhaps the best-known animal model relating stress to atherosclerosis was developed by Kaplan et al. (1982) . Their study was carried out on male cynomolgus monkeys, who normally live in social groups. The investigators stressed half the animals by reorganizing five-member social groups at one- to three-month intervals on a schedule that ensured that each monkey would be housed with several new animals during each reorganization. The other half of the animals lived in stable social groups. All animals were maintained on a moderately atherogenic diet for 22 months. Animals were also assessed for their social status (i.e., relative dominance) within each group. The major findings were that ( a ) socially dominant animals living in unstable groups had significantly more atherosclerosis than did less dominant animals living in unstable groups; and ( b ) socially dominant male animals living in unstable groups had significantly more atherosclerosis than did socially dominant animals living in stable groups. Other important findings based upon this model have been that heart-rate reactivity to the threat of capture predicts severity of atherosclerosis ( Manuck et al. 1983 ) and that administration of the SNS-blocking agent propranolol decreases the progression of atherosclerosis ( Kaplan et al. 1987 ). In contrast to the findings in males, subordinate premenstrual females develop greater atherosclerosis than do dominant females ( Kaplan et al. 1984 ) because they are relatively estrogen deficient, tending to miss ovulatory cycles ( Adams et al. 1985 ).

Whereas the studies in cynomolgus monkeys indicate that emotionally stressful behavior can accelerate the progression of atherosclerosis, McCabe et al. (2002) have provided evidence that affiliative social behavior can slow the progression of atherosclerosis in the Watanabe heritable hyperlipidemic rabbit. This rabbit model has a genetic defect in lipoprotein clearance such that it exhibits hypercholesterolemia and severe atherosclerosis. The rabbits were assigned to one of three social or behavioral groups: ( a ) an unstable group in which unfamiliar rabbits were paired daily, with the pairing switched each week; ( b ) a stable group, in which littermates were paired daily for the entire study; and ( c ) an individually caged group. The stable group exhibited more affiliative behavior and less agonistic behavior than the unstable group and significantly less atherosclerosis than each of the other two groups. The study emphasizes the importance of behavioral factors in atherogenesis, even in a model of disease with extremely strong genetic determinants.

Upper Respiratory Diseases

The hypothesis that stress predicts susceptibility to the common cold received support from observational studies ( Graham et al. 1986 , Meyer & Haggerty 1962 ). One problem with such studies is that they do not control for exposure. Stressed people, for instance, might seek more outside contact and thus be exposed to more viruses. Therefore, in a more controlled study, people were exposed to a rhinovirus and then quarantined to control for exposure to other viruses ( Cohen et al. 1991 ). Those individuals with the most stressful life events and highest levels of perceived stress and negative affect had the greatest probability of developing cold symptoms. In a subsequent study of volunteers inoculated with a cold virus, it was found that people enduring chronic, stressful life events (i.e., events lasting a month or longer including unemployment, chronic underemployment, or continued interpersonal difficulties) had a high likelihood of catching cold, whereas people subjected to stressful events lasting less than a month did not ( Cohen et al. 1998 ).

Human Immunodeficiency Virus

The impact of life stressors has also been studied within the context of human immunodeficiency virus (HIV) spectrum disease. Leserman et al. (2000) followed men with HIV for up to 7.5 years and found that faster progression to AIDS was associated with higher cumulative stressful life events, use of denial as a coping mechanism, lower satisfaction with social support, and elevated serum cortisol.

Inflammation, the Immune System, and Physical Health

Despite the stress-mediated immunosuppressive effects reviewed above, stress has also been associated with exacerbations of autoimmune disease ( Harbuz et al. 2003 ) and other conditions in which excessive inflammation is a central feature, such as CHD ( Appels et al. 2000 ). Evidence suggests that a chronically activated, dysregulated acute stress response is responsible for these associations. Recall that the acute stress response includes the activation and migration of cells of the innate immune system. This effect is mediated by proinflammatory cytokines. During periods of chronic stress, in the otherwise healthy individual, cortisol eventually suppresses proinflammatory cytokine production. But in individuals with autoimmune disease or CHD, prolonged stress can cause proinflammatory cytokine production to remain chronically activated, leading to an exacerbation of pathophysiology and symptomatology.

Miller et al. (2002) proposed the glucocorticoid-resistance model to account for this deficit in proinflammatory cytokine regulation. They argue that immune cells become “resistant” to the effects of cortisol (i.e., a type of glucocorticoid), primarily through a reduction, or downregulation, in the number of expressed cortisol receptors. With cortisol unable to suppress inflammation, stress continues to promote proinflammatory cytokine production indefinitely. Although there is only preliminary empirical support for this model, it could have implications for diseases of inflammation. For example, in rheumatoid arthritis, excessive inflammation is responsible for joint damage, swelling, pain, and reduced mobility. Stress is associated with more swelling and reduced mobility in rheumatoid arthritis patients ( Affleck et al. 1997 ). Similarly, in multiple sclerosis (MS), an overactive immune system targets and destroys the myelin surrounding nerves, contributing to a host of symptoms that include paralysis and blindness. Again, stress is associated with an exacerbation of disease ( Mohr et al. 2004 ). Even in CHD, inflammation plays a role. The immune system responds to vascular injury just as it would any other wound: Immune cells migrate to and infiltrate the arterial wall, setting off a cascade of biochemical processes that can ultimately lead to a thrombosis (i.e., clot; Ross 1999 ). Elevated levels of inflammatory markers, such as C-reactive protein (CRP), are predictive of heart attacks, even when controlling for other traditional risk factors (e.g., cholesterol, blood pressure, and smoking; Morrow & Ridker 2000 ). Interestingly, a history of major depressive episodes has been associated with elevated levels of CRP in men ( Danner et al. 2003 ).

Inflammation, Cytokine Production, and Mental Health

In addition to its effects on physical health, prolonged proinflammatory cytokine production may also adversely affect mental health in vulnerable individuals. During times of illness (e.g., the flu), proinflammatory cytokines feed back to the CNS and produce symptoms of fatigue, malaise, diminished appetite, and listlessness, which are symptoms usually associated with depression. It was once thought that these symptoms were directly caused by infectious pathogens, but more recently, it has become clear that proinflammatory cytokines are both sufficient and necessary (i.e., even absent infection or fever) to generate sickness behavior ( Dantzer 2001 , Larson & Dunn 2001 ).

Sickness behavior has been suggested to be a highly organized strategy that mammals use to combat infection ( Dantzer 2001 ). Symptoms of illness, as previously thought, are not inconsequential or even maladaptive. On the contrary, sickness behavior is thought to promote resistance and facilitate recovery. For example, an overall decrease in activity allows the sick individual to preserve energy resources that can be redirected toward enhancing immune activity. Similarly, limiting exploration, mating, and foraging further preserves energy resources and reduces the likelihood of risky encounters (e.g., fighting over a mate). Furthermore, decreasing food intake also decreases the level of iron in the blood, thereby decreasing bacterial replication. Thus, for a limited period, sickness behavior may be looked upon as an adaptive response to the stress of illness.

Much like other aspects of the acute stress response, however, sickness behavior can become maladaptive when repeatedly or continuously activated. Many features of the sickness behavior response overlap with major depression. Indeed, compared with healthy controls, elevated rates of depression are reported in patients with inflammatory diseases such as MS ( Mohr et al. 2004 ) or CHD ( Carney et al. 1987 ). Granted, MS patients face a number of stressors and reports of depression are not surprising. However, when compared with individuals facing similar disability who do not have MS (e.g., car accident victims), MS patients still report higher levels of depression ( Ron & Logsdail 1989 ). In both MS ( Fassbender et al. 1998 ) and CHD ( Danner et al. 2003 ), indicators of inflammation have been found to be correlated with depressive symptomatology. Thus, there is evidence to suggest that stress contributes to both physical and mental disease through the mediating effects of proinflammatory cytokines.

HOST VULNERABILITY-STRESSOR INTERACTIONS AND DISEASE

The changes in biological set points that occur across the life span as a function of chronic stressors are referred to as allostasis, and the biological cost of these adjustments is known as allostatic load ( McEwen 1998 ). McEwen has also suggested that cumulative increases in allostatic load are related to chronic illness. These are intriguing hypotheses that emphasize the role that stressors may play in disease. The challenge, however, is to show the exact interactions that occur among stressors, pathogens, host vulnerability (both constitutional and genetic), and such poor health behaviors as smoking, alcohol abuse, and excessive caloric consumption. Evidence of a lifetime trajectory of comorbidities does not necessarily imply that allostatic load is involved since immunosenescence, genetic predisposition, pathogen exposure, and poor health behaviors may act as culprits.

It is not clear, for example, that changes in set point for variables such as blood pressure are related to cumulative stressors per se, at least in healthy young individuals. Thus, for example, British soldiers subjected to battlefield conditions for more than a year in World War II showed chronic elevations in blood pressure, which returned to normal after a couple of months away from the front ( Graham 1945 ). In contrast, individuals with chronic illnesses such as chronic fatigue syndrome may show a high rate of relapse after a relatively acute stressor such as a hurricane ( Lutgendorf et al. 1995 ). Nevertheless, by emphasizing the role that chronic stressors may play in multiple disease outcomes, McEwen has helped to emphasize an important area of study.

TREATMENT FOR STRESS-RELATED DISORDERS

For PTSD, useful treatments include cognitive-behavioral therapy (CBT), along with exposure and the more controversial Eye Movement Desensitization and Reprocessing ( Foa & Meadows 1997 , Ironson et al. 2002 , Shapiro 1995 ). Psychopharmacological approaches have also been suggested ( Berlant 2001 ). In addition, writing about trauma has been helpful both for affective recovery and for potential health benefit ( Pennebaker 1997 ). For outpatients with major depression, Beck’s CBT ( Beck 1976 ) and interpersonal therapy ( Klerman et al. 1984 ) are as effective as psychopharmacotherapy ( Clinical Practice Guidelines 1993 ). However, the presence of sleep problems or hypercortisolemia is associated with poorer response to psychotherapy ( Thase 2000 ). The combination of psychotherapy and pharmacotherapy seems to offer a substantial advantage over psychotherapy alone for the subset of patients who are more severely depressed or have recurrent depression ( Thase et al. 1997 ). For the treatment of anxiety, it depends partly on the specific disorder [e.g., generalized anxiety disorder (GAD), panic disorder, social phobia], although CBT including relaxation training has demonstrated efficacy in several subtypes of anxiety ( Borkovec & Ruscio 2001 ). Antidepressants such as selective serotonin reuptake inhibitors also show efficacy in anxiety ( Ballenger et al. 2001 ), especially when GAD is comorbid with major depression, which is the case in 39% of subjects with current GAD ( Judd et al. 1998 ).

BEHAVIORAL INTERVENTIONS IN CHRONIC DISEASE

Patients dealing with chronic, life-threatening diseases must often confront daily stressors that can threaten to undermine even the most resilient coping strategies and overwhelm the most abundant interpersonal resources. Psychosocial interventions, such as cognitive-behavioral stress management (CBSM), have a positive effect on the quality of life of patients with chronic disease ( Schneiderman et al. 2001 ). Such interventions decrease perceived stress and negative mood (e.g., depression), improve perceived social support, facilitate problem-focused coping, and change cognitive appraisals, as well as decrease SNS arousal and the release of cortisol from the adrenal cortex. Psychosocial interventions also appear to help chronic pain patients reduce their distress and perceived pain as well as increase their physical activity and ability to return to work ( Morley et al. 1999 ). These psychosocial interventions can also decrease patients’ overuse of medications and utilization of the health care system. There is also some evidence that psychosocial interventions may have a favorable influence on disease progression ( Schneiderman et al. 2001 ).

Morbidity, Mortality, and Markers of Disease Progression

Psychosocial intervention trials conducted upon patients following acute myocardial infarction (MI) have reported both positive and null results. Two meta-analyses have reported a reduction in both mortality and morbidity of approximately 20% to 40% ( Dusseldorp et al. 1999 , Linden et al. 1996 ). Most of these studies were carried out in men. The major study reporting positive results was the Recurrent Coronary Prevention Project (RCPP), which employed group-based CBT, and decreased hostility and depressed affect ( Mendes de Leon et al. 1991 ), as well as the composite medical end point of cardiac death and nonfatal MI ( Friedman et al. 1986 ).

In contrast, the major study reporting null results for medical end points was the Enhancing Recovery in Coronary Heart Disease (ENRICHD) clinical trial ( Writing Committee for ENRICHD Investigators 2003 ), which found that the intervention modestly decreased depression and increased perceived social support, but did not affect the composite medical end point of death and nonfatal MI. However, a secondary analysis, which examined the effects of the psychosocial intervention within gender by ethnicity subgroups, found significant decreases approaching 40% in both cardiac death and nonfatal MI for white men but not for other subgroups such as minority women ( Schneiderman et al. 2004 ). Although there were important differences between the RCPP and ENRICHD in terms of the objectives of psychosocial intervention and the duration and timing of treatment, it should also be noted that more than 90% of the patients in the RCPP were white men. Thus, because primarily white men, but not other subgroups, may have benefited from the ENRICHD intervention, future studies need to attend to variables that may have prevented morbidity and mortality benefits among gender and ethnic subgroups other than white men.

Psychosocial intervention trials conducted upon patients with cancer have reported both positive and null results with regard to survival ( Classen 1998 ). A number of factors that generally characterized intervention trials that observed significant positive effects on survival were relatively absent in trials that failed to show improved survival. These included: ( a ) having only patients with the same type and severity of cancer within each group, ( b ) creation of a supportive environment, ( c ) having an educational component, and ( d ) provision of stress-management and coping-skills training. In one study that reported positive results, Fawzy et al. (1993) found that patients with early stage melanoma assigned to a six-week cognitive-behavioral stress management (CBSM) group showed significantly longer survival and longer time to recurrence over a six-year follow-up period compared with those receiving surgery and standard care alone. The intervention also significantly reduced distress, enhanced active coping, and increased NK cell cytotoxicity compared with controls.

Although published studies have not yet shown that psychosocial interventions can decrease disease progression in HIV/AIDS, several studies have significantly influenced factors that have been associated with HIV/AIDS disease progression ( Schneiderman & Antoni 2003 ). These variables associated with disease progression include distress, depressed affect, denial coping, low perceived social support, and elevated serum cortisol ( Ickovics et al. 2001 , Leserman et al. 2000 ). Antoni et al. have used group-based CBSM (i.e., CBT plus relaxation training) to decrease the stress-related effects of HIV+ serostatus notification. Those in the intervention condition showed lower distress, anxiety, and depressed mood than did those in the control condition as well as lower antibody titers of herpesviruses and higher levels of T-helper (CD4) cells, NK cells, and lymphocyte proliferation ( Antoni et al. 1991 , Esterling et al. 1992 ). In subsequent studies conducted upon symptomatic HIV+ men who were not attempting to determine their HIV serostatus, CBSM decreased distress, dysphoria, anxiety, herpesvirus antibody titers, cortisol, and epinephrine ( Antoni et al. 2000a , b ; Lutgendorf et al. 1997 ). Improvement in perceived social support and adaptive coping skills mediated the decreases in distress ( Lutgendorf et al. 1998 ). In summary, it appears that CBSM can positively influence stress-related variables that have been associated with HIV/AIDS progression. Only a randomized clinical trial, however, could document that CBSM can specifically decrease HIV/AIDS disease progression.

Stress is a central concept for understanding both life and evolution. All creatures face threats to homeostasis, which must be met with adaptive responses. Our future as individuals and as a species depends on our ability to adapt to potent stressors. At a societal level, we face a lack of institutional resources (e.g., inadequate health insurance), pestilence (e.g., HIV/AIDS), war, and international terrorism that has reached our shores. At an individual level, we live with the insecurities of our daily existence including job stress, marital stress, and unsafe schools and neighborhoods. These are not an entirely new condition as, in the last century alone, the world suffered from instances of mass starvation, genocide, revolutions, civil wars, major infectious disease epidemics, two world wars, and a pernicious cold war that threatened the world order. Although we have chosen not to focus on these global threats in this paper, they do provide the backdrop for our consideration of the relationship between stress and health.

A widely used definition of stressful situations is one in which the demands of the situation threaten to exceed the resources of the individual ( Lazarus & Folkman 1984 ). It is clear that all of us are exposed to stressful situations at the societal, community, and interpersonal level. How we meet these challenges will tell us about the health of our society and ourselves. Acute stress responses in young, healthy individuals may be adaptive and typically do not impose a health burden. Indeed, individuals who are optimistic and have good coping responses may benefit from such experiences and do well dealing with chronic stressors ( Garmezy 1991 , Glanz & Johnson 1999 ). In contrast, if stressors are too strong and too persistent in individuals who are biologically vulnerable because of age, genetic, or constitutional factors, stressors may lead to disease. This is particularly the case if the person has few psychosocial resources and poor coping skills. In this chapter, we have documented associations between stressors and disease and have described how endocrine-immune interactions appear to mediate the relationship. We have also described how psychosocial stressors influence mental health and how psychosocial treatments may ameliorate both mental and physical disorders. There is much we do not yet know about the relationship between stress and health, but scientific findings being made in the areas of cognitive-emotional psychology, molecular biology, neuroscience, clinical psychology, and medicine will undoubtedly lead to improved health outcomes.

ACKNOWLEDGMENTS

Preparation of this manuscript was supported by NIH grants P01-MH49548, P01- HL04726, T32-HL36588, R01-MH66697, and R01-AT02035. We thank Elizabeth Balbin, Adam Carrico, and Orit Weitzman for library research.

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Article contents

Work, stress, coping, and stress management.

• Sharon Glazer Sharon Glazer University of Baltimore
•  and  Cong Liu Cong Liu Hofstra University
• https://doi.org/10.1093/acrefore/9780190236557.013.30
• Published online: 26 April 2017

Work stress refers to the process of job stressors, or stimuli in the workplace, leading to strains, or negative responses or reactions. Organizational development refers to a process in which problems or opportunities in the work environment are identified, plans are made to remediate or capitalize on the stimuli, action is taken, and subsequently the results of the plans and actions are evaluated. When organizational development strategies are used to assess work stress in the workplace, the actions employed are various stress management interventions. Two key factors tying work stress and organizational development are the role of the person and the role of the environment. In order to cope with work-related stressors and manage strains, organizations must be able to identify and differentiate between factors in the environment that are potential sources of stressors and how individuals perceive those factors. Primary stress management interventions focus on preventing stressors from even presenting, such as by clearly articulating workers’ roles and providing necessary resources for employees to perform their job. Secondary stress management interventions focus on a person’s appraisal of job stressors as a threat or challenge, and the person’s ability to cope with the stressors (presuming sufficient internal resources, such as a sense of meaningfulness in life, or external resources, such as social support from a supervisor). When coping is not successful, strains may develop. Tertiary stress management interventions attempt to remediate strains, by addressing the consequence itself (e.g., diabetes management) and/or the source of the strain (e.g., reducing workload). The person and/or the organization may be the targets of the intervention. The ultimate goal of stress management interventions is to minimize problems in the work environment, intensify aspects of the work environment that create a sense of a quality work context, enable people to cope with stressors that might arise, and provide tools for employees and organizations to manage strains that might develop despite all best efforts to create a healthy workplace.

• stress management
• organization development
• organizational interventions
• stress theories and frameworks

Introduction

Work stress is a generic term that refers to work-related stimuli (aka job stressors) that may lead to physical, behavioral, or psychological consequences (i.e., strains) that affect both the health and well-being of the employee and the organization. Not all stressors lead to strains, but all strains are a result of stressors, actual or perceived. Common terms often used interchangeably with work stress are occupational stress, job stress, and work-related stress. Terms used interchangeably with job stressors include work stressors, and as the specificity of the type of stressor might include psychosocial stressor (referring to the psychological experience of work demands that have a social component, e.g., conflict between two people; Hauke, Flintrop, Brun, & Rugulies, 2011 ), hindrance stressor (i.e., a stressor that prevents goal attainment; Cavanaugh, Boswell, Roehling, & Boudreau, 2000 ), and challenge stressor (i.e., a stressor that is difficult, but attainable and possibly rewarding to attain; Cavanaugh et al., 2000 ).

Stress in the workplace continues to be a highly pervasive problem, having both direct negative effects on individuals experiencing it and companies paying for it, and indirect costs vis à vis lost productivity (Dopkeen & DuBois, 2014 ). For example, U.K. public civil servants’ work-related stress rose from 10.8% in 2006 to 22.4% in 2013 and about one-third of the workforce has taken more than 20 days of leave due to stress-related ill-health, while well over 50% are present at work when ill (French, 2015 ). These findings are consistent with a report by the International Labor Organization (ILO, 2012 ), whereby 50% to 60% of all workdays are lost due to absence attributed to factors associated with work stress.

The prevalence of work-related stress is not diminishing despite improvements in technology and employment rates. The sources of stress, such as workload, seem to exacerbate with improvements in technology (Coovert & Thompson, 2003 ). Moreover, accessibility through mobile technology and virtual computer terminals is linking people to their work more than ever before (ILO, 2012 ; Tarafdar, Tu, Ragu-Nathan, & Ragu-Nathan, 2007 ). Evidence of this kind of mobility and flexibility is further reinforced in a June 2007 survey of 4,025 email users (over 13 years of age); AOL reported that four in ten survey respondents reported planning their vacations around email accessibility and 83% checked their emails at least once a day while away (McMahon, 2007 ). Ironically, despite these mounting work-related stressors and clear financial and performance outcomes, some individuals are reporting they are less “stressed,” but only because “stress has become the new normal” (Jayson, 2012 , para. 4).

This new normal is likely the source of psychological and physiological illness. Siegrist ( 2010 ) contends that conditions in the workplace, particularly psychosocial stressors that are perceived as unfavorable relationships with others and self, and an increasingly sedentary lifestyle (reinforced with desk jobs) are increasingly contributing to cardiovascular disease. These factors together justify a need to continue on the path of helping individuals recognize and cope with deleterious stressors in the work environment and, equally important, to find ways to help organizations prevent harmful stressors over which they have control, as well as implement policies or mechanisms to help employees deal with these stressors and subsequent strains. Along with a greater focus on mitigating environmental constraints are interventions that can be used to prevent anxiety, poor attitudes toward the workplace conditions and arrangements, and subsequent cardiovascular illness, absenteeism, and poor job performance (Siegrist, 2010 ).

Even the ILO has presented guidance on how the workplace can help prevent harmful job stressors (aka hindrance stressors) or at least help workers cope with them. Consistent with the view that well-being is not the absence of stressors or strains and with the view that positive psychology offers a lens for proactively preventing stressors, the ILO promotes increasing preventative risk assessments, interventions to prevent and control stressors, transparent organizational communication, worker involvement in decision-making, networks and mechanisms for workplace social support, awareness of how working and living conditions interact, safety, health, and well-being in the organization (ILO, n.d. ). The field of industrial and organizational (IO) psychology supports the ILO’s recommendations.

IO psychology views work stress as the process of a person’s interaction with multiple aspects of the work environment, job design, and work conditions in the organization. Interventions to manage work stress, therefore, focus on the psychosocial factors of the person and his or her relationships with others and the socio-technical factors related to the work environment and work processes. Viewing work stress from the lens of the person and the environment stems from Kurt Lewin’s ( 1936 ) work that stipulates a person’s state of mental health and behaviors are a function of the person within a specific environment or situation. Aspects of the work environment that affect individuals’ mental states and behaviors include organizational hierarchy, organizational climate (including processes, policies, practices, and reward structures), resources to support a person’s ability to fulfill job duties, and management structure (including leadership). Job design refers to each contributor’s tasks and responsibilities for fulfilling goals associated with the work role. Finally, working conditions refers not only to the physical environment, but also the interpersonal relationships with other contributors.

Each of the conditions that are identified in the work environment may be perceived as potentially harmful or a threat to the person or as an opportunity. When a stressor is perceived as a threat to attaining desired goals or outcomes, the stressor may be labeled as a hindrance stressor (e.g., LePine, Podsakoff, & Lepine, 2005 ). When the stressor is perceived as an opportunity to attain a desired goal or end state, it may be labeled as a challenge stressor. According to LePine and colleagues’ ( 2005 ), both challenge (e.g., time urgency, workload) and hindrance (e.g., hassles, role ambiguity, role conflict) stressors could lead to strains (as measured by “anxiety, depersonalization, depression, emotional exhaustion, frustration, health complaints, hostility, illness, physical symptoms, and tension” [p. 767]). However, challenge stressors positively relate with motivation and performance, whereas hindrance stressors negatively relate with motivation and performance. Moreover, motivation and strains partially mediate the relationship between hindrance and challenge stressors with performance.

Figure 1. Organizational development frameworks to guide identification of work stress and interventions.

In order to (1) minimize any potential negative effects from stressors, (2) increase coping skills to deal with stressors, or (3) manage strains, organizational practitioners or consultants will devise organizational interventions geared toward prevention, coping, and/or stress management. Ultimately, toxic factors in the work environment can have deleterious effects on a person’s physical and psychological well-being, as well as on an organization’s total health. It behooves management to take stock of the organization’s health, which includes the health and well-being of its employees, if the organization wishes to thrive and be profitable. According to Page and Vella-Brodrick’s ( 2009 ) model of employee well-being, employee well-being results from subjective well-being (i.e., life satisfaction and general positive or negative affect), workplace well-being (composed of job satisfaction and work-specific positive or negative affect), and psychological well-being (e.g., self-acceptance, positive social relations, mastery, purpose in life). Job stressors that become unbearable are likely to negatively affect workplace well-being and thus overall employee well-being. Because work stress is a major organizational pain point and organizations often employ organizational consultants to help identify and remediate pain points, the focus here is on organizational development (OD) frameworks; several work stress frameworks are presented that together signal areas where organizations might focus efforts for change in employee behaviors, attitudes, and performance, as well as the organization’s performance and climate. Work stress, interventions, and several OD and stress frameworks are depicted in Figure 1 .

The goals are: (1) to conceptually define and clarify terms associated with stress and stress management, particularly focusing on organizational factors that contribute to stress and stress management, and (2) to present research that informs current knowledge and practices on workplace stress management strategies. Stressors and strains will be defined, leading OD and work stress frameworks that are used to organize and help organizations make sense of the work environment and the organization’s responsibility in stress management will be explored, and stress management will be explained as an overarching thematic label; an area of study and practice that focuses on prevention (primary) interventions, coping (secondary) interventions, and managing strains (tertiary) interventions; as well as the label typically used to denote tertiary interventions. Suggestions for future research and implications toward becoming a healthy organization are presented.

Defining Stressors and Strains

Work-related stressors or job stressors can lead to different kinds of strains individuals and organizations might experience. Various types of stress management interventions, guided by OD and work stress frameworks, may be employed to prevent or cope with job stressors and manage strains that develop(ed).

A job stressor is a stimulus external to an employee and a result of an employee’s work conditions. Example job stressors include organizational constraints, workplace mistreatments (such as abusive supervision, workplace ostracism, incivility, bullying), role stressors, workload, work-family conflicts, errors or mistakes, examinations and evaluations, and lack of structure (Jex & Beehr, 1991 ; Liu, Spector, & Shi, 2007 ; Narayanan, Menon, & Spector, 1999 ). Although stressors may be categorized as hindrances and challenges, there is not yet sufficient information to be able to propose which stress management interventions would better serve to reduce those hindrance stressors or to reduce strain-producing challenge stressors while reinforcing engagement-producing challenge stressors.

Organizational Constraints

Organizational constraints may be hindrance stressors as they prevent employees from translating their motivation and ability into high-level job performance (Peters & O’Connor, 1980 ). Peters and O’Connor ( 1988 ) defined 11 categories of organizational constraints: (1) job-related information, (2) budgetary support, (3) required support, (4) materials and supplies, (5) required services and help from others, (6) task preparation, (7) time availability, (8) the work environment, (9) scheduling of activities, (10) transportation, and (11) job-relevant authority. The inhibiting effect of organizational constraints may be due to the lack of, inadequacy of, or poor quality of these categories.

Workplace Mistreatment

Workplace mistreatment presents a cluster of interpersonal variables, such as interpersonal conflict, bullying, incivility, and workplace ostracism (Hershcovis, 2011 ; Tepper & Henle, 2011 ). Typical workplace mistreatment behaviors include gossiping, rude comments, showing favoritism, yelling, lying, and ignoring other people at work (Tepper & Henle, 2011 ). These variables relate to employees’ psychological well-being, physical well-being, work attitudes (e.g., job satisfaction and organizational commitment), and turnover intention (e.g., Hershcovis, 2011 ; Spector & Jex, 1998 ). Some researchers differentiated the source of mistreatment, such as mistreatment from one’s supervisor versus mistreatment from one’s coworker (e.g., Bruk-Lee & Spector, 2006 ; Frone, 2000 ; Liu, Liu, Spector, & Shi, 2011 ).

Role Stressors

Role stressors are demands, constraints, or opportunities a person perceives to be associated, and thus expected, with his or her work role(s) across various situations. Three commonly studied role stressors are role ambiguity, role conflict, and role overload (Glazer & Beehr, 2005 ; Kahn, Wolfe, Quinn, Snoek, & Rosenthal, 1964 ). Role ambiguity in the workplace occurs when an employee lacks clarity regarding what performance-related behaviors are expected of him or her. Role conflict refers to situations wherein an employee receives incompatible role requests from the same or different supervisors or the employee is asked to engage in work that impedes his or her performance in other work or nonwork roles or clashes with his or her values. Role overload refers to excessive demands and insufficient time (quantitative) or knowledge (qualitative) to complete the work. The construct is often used interchangeably with workload, though role overload focuses more on perceived expectations from others about one’s workload. These role stressors significantly relate to low job satisfaction, low organizational commitment, low job performance, high tension or anxiety, and high turnover intention (Abramis, 1994 ; Glazer & Beehr, 2005 ; Jackson & Schuler, 1985 ).

Excessive workload is one of the most salient stressors at work (e.g., Liu et al., 2007 ). There are two types of workload: quantitative and qualitative workload (LaRocco, Tetrick, & Meder, 1989 ; Parasuraman & Purohit, 2000 ). Quantitative workload refers to the excessive amount of work one has. In a summary of a Chartered Institute of Personnel & Development Report from 2006 , Dewe and Kompier ( 2008 ) noted that quantitative workload was one of the top three stressors workers experienced at work. Qualitative workload refers to the difficulty of work. Workload also differs by the type of the load. There are mental workload and physical workload (Dwyer & Ganster, 1991 ). Excessive physical workload may result in physical discomfort or illness. Excessive mental workload will cause psychological distress such as anxiety or frustration (Bowling & Kirkendall, 2012 ). Another factor affecting quantitative workload is interruptions (during the workday). Lin, Kain, and Fritz ( 2013 ) found that interruptions delay completion of job tasks, thus adding to the perception of workload.

Work-Family Conflict

Work-family conflict is a form of inter-role conflict in which demands from one’s work domain and one’s family domain are incompatible to some extent (Greenhaus & Beutell, 1985 ). Work can interfere with family (WIF) and/or family can interfere with work (FIW) due to time-related commitments to participating in one domain or another, incompatible behavioral expectations, or when strains in one domain carry over to the other (Greenhaus & Beutell, 1985 ). Work-family conflict significantly relates to work-related outcomes (e.g., job satisfaction, organizational commitment, turnover intention, burnout, absenteeism, job performance, job strains, career satisfaction, and organizational citizenship behaviors), family-related outcomes (e.g., marital satisfaction, family satisfaction, family-related performance, family-related strains), and domain-unspecific outcomes (e.g., life satisfaction, psychological strain, somatic or physical symptoms, depression, substance use or abuse, and anxiety; Amstad, Meier, Fasel, Elfering, & Semmer, 2011 ).

Individuals and organizations can experience work-related strains. Sometimes organizations will experience strains through the employee’s negative attitudes or strains, such as that a worker’s absence might yield lower production rates, which would roll up into an organizational metric of organizational performance. In the industrial and organizational (IO) psychology literature, organizational strains are mostly observed as macro-level indicators, such as health insurance costs, accident-free days, and pervasive problems with company morale. In contrast, individual strains, usually referred to as job strains, are internal to an employee. They are responses to work conditions and relate to health and well-being of employees. In other words, “job strains are adverse reactions employees have to job stressors” (Spector, Chen, & O’Connell, 2000 , p. 211). Job strains tend to fall into three categories: behavioral, physical, and psychological (Jex & Beehr, 1991 ).

Behavioral strains consist of actions that employees take in response to job stressors. Examples of behavioral strains include employees drinking alcohol in the workplace or intentionally calling in sick when they are not ill (Spector et al., 2000 ). Physical strains consist of health symptoms that are physiological in nature that employees contract in response to job stressors. Headaches and ulcers are examples of physical strains. Lastly, psychological strains are emotional reactions and attitudes that employees have in response to job stressors. Examples of psychological strains are job dissatisfaction, anxiety, and frustration (Spector et al., 2000 ). Interestingly, research studies that utilize self-report measures find that most job strains experienced by employees tend to be psychological strains (Spector et al., 2000 ).

Leading Frameworks

Organizations that are keen on identifying organizational pain points and remedying them through organizational campaigns or initiatives often discover the pain points are rooted in work-related stressors and strains and the initiatives have to focus on reducing workers’ stress and increasing a company’s profitability. Through organizational climate surveys, for example, companies discover that aspects of the organization’s environment, including its policies, practices, reward structures, procedures, and processes, as well as employees at all levels of the company, are contributing to the individual and organizational stress. Recent studies have even begun to examine team climates for eustress and distress assessed in terms of team members’ homogenous psychological experience of vigor, efficacy, dedication, and cynicism (e.g., Kożusznik, Rodriguez, & Peiro, 2015 ).

Each of the frameworks presented advances different aspects that need to be identified in order to understand the source and potential remedy for stressors and strains. In some models, the focus is on resources, in others on the interaction of the person and environment, and in still others on the role of the person in the workplace. Few frameworks directly examine the role of the organization, but the organization could use these frameworks to plan interventions that would minimize stressors, cope with existing stressors, and prevent and/or manage strains. One of the leading frameworks in work stress research that is used to guide organizational interventions is the person and environment (P-E) fit (French & Caplan, 1972 ). Its precursor is the University of Michigan Institute for Social Research’s (ISR) role stress model (Kahn, Wolfe, Quinn, Snoek, & Rosenthal, 1964 ) and Lewin’s Field Theory. Several other theories have since evolved from the P-E fit framework, including Karasek and Theorell’s ( 1990 ), Karasek ( 1979 ) Job Demands-Control Model (JD-C), the transactional framework (Lazarus & Folkman, 1984 ), Conservation of Resources (COR) theory (Hobfoll, 1989 ), and Siegrist’s ( 1996 ) Effort-Reward Imbalance (ERI) Model.

Field Theory

The premise of Kahn et al.’s ( 1964 ) role stress theory is Lewin’s ( 1997 ) Field Theory. Lewin purported that behavior and mental events are a dynamic function of the whole person, including a person’s beliefs, values, abilities, needs, thoughts, and feelings, within a given situation (field or environment), as well as the way a person represents his or her understanding of the field and behaves in that space. Lewin explains that work-related strains are a result of individuals’ subjective perceptions of objective factors, such as work roles, relationships with others in the workplace, as well as personality indicators, and can be used to predict people’s reactions, including illness. Thus, to make changes to an organizational system, it is necessary to understand a field and try to move that field from the current state to the desired state. Making this move necessitates identifying mechanisms influencing individuals.

Role Stress Theory

Role stress theory mostly isolates the perspective a person has about his or her work-related responsibilities and expectations to determine how those perceptions relate with a person’s work-related strains. However, those relationships have been met with somewhat varied results, which Glazer and Beehr ( 2005 ) concluded might be a function of differences in culture, an environmental factor often neglected in research. Kahn et al.’s ( 1964 ) role stress theory, coupled with Lewin’s ( 1936 ) Field Theory, serves as the foundation for the P-E fit theory. Lewin ( 1936 ) wrote, “Every psychological event depends upon the state of the person and at the same time on the environment” (p. 12). Researchers of IO psychology have narrowed the environment to the organization or work team. This narrowed view of the organizational environment is evident in French and Caplan’s ( 1972 ) P-E fit framework.

Person-Environment Fit Theory

The P-E fit framework focuses on the extent to which there is congruence between the person and a given environment, such as the organization (Caplan, 1987 ; Edwards, 2008 ). For example, does the person have the necessary skills and abilities to fulfill an organization’s demands, or does the environment support a person’s desire for autonomy (i.e., do the values align?) or fulfill a person’s needs (i.e., a person’s needs are rewarded). Theoretically and empirically, the greater the person-organization fit, the greater a person’s job satisfaction and organizational commitment, the less a person’s turnover intention and work-related stress (see meta-analyses by Assouline & Meir, 1987 ; Kristof-Brown, Zimmerman, & Johnson, 2005 ; Verquer, Beehr, & Wagner, 2003 ).

Job Demands-Control/Support (JD-C/S) and Job Demands-Resources (JD-R) Model

Focusing more closely on concrete aspects of work demands and the extent to which a person perceives he or she has control or decision latitude over those demands, Karasek ( 1979 ) developed the JD-C model. Karasek and Theorell ( 1990 ) posited that high job demands under conditions of little decision latitude or control yield high strains, which have varied implications on the health of an organization (e.g., in terms of high turnover, employee ill-health, poor organizational performance). This theory was modified slightly to address not only control, but also other resources that could protect a person from unruly job demands, including support (aka JD-C/S, Johnson & Hall, 1988 ; and JD-R, Bakker, van Veldhoven, & Xanthopoulou, 2010 ). Whether focusing on control or resources, both they and job demands are said to reflect workplace characteristics, while control and resources also represent coping strategies or tools (Siegrist, 2010 ).

Despite the glut of research testing the JD-C and JD-R, results are somewhat mixed. Testing the interaction between job demands and control, Beehr, Glaser, Canali, and Wallwey ( 2001 ) did not find empirical support for the JD-C theory. However, Dawson, O’Brien, and Beehr ( 2016 ) found that high control and high support buffered against the independent deleterious effects of interpersonal conflict, role conflict, and organizational politics (demands that were categorized as hindrance stressors) on anxiety, as well as the effects of interpersonal conflict and organizational politics on physiological symptoms, but control and support did not moderate the effects between challenge stressors and strains. Coupled with Bakker, Demerouti, and Sanz-Vergel’s ( 2014 ) note that excessive job demands are a source of strain, but increased job resources are a source of engagement, Dawson et al.’s results suggest that when an organization identifies that demands are hindrances, it can create strategies for primary (preventative) stress management interventions and attempt to remove or reduce such work demands. If the demands are challenging, though manageable, but latitude to control the challenging stressors and support are insufficient, the organization could modify practices and train employees on adopting better strategies for meeting or coping (secondary stress management intervention) with the demands. Finally, if the organization can neither afford to modify the demands or the level of control and support, it will be necessary for the organization to develop stress management (tertiary) interventions to deal with the inevitable strains.

Conservation of Resources Theory

The idea that job resources reinforce engagement in work has been propagated in Hobfoll’s ( 1989 ) Conservation of Resources (COR) theory. COR theory also draws on the foundational premise that people’s mental health is a function of the person and the environment, forwarding that how people interpret their environment (including the societal context) affects their stress levels. Hobfoll focuses on resources such as objects, personal characteristics, conditions, or energies as particularly instrumental to minimizing strains. He asserts that people do whatever they can to protect their valued resources. Thus, strains develop when resources are threatened to be taken away, actually taken away, or when additional resources are not attainable after investing in the possibility of gaining more resources (Hobfoll, 2001 ). By extension, organizations can invest in activities that would minimize resource loss and create opportunities for resource gains and thus have direct implications for devising primary and secondary stress management interventions.

Transactional Framework

Lazarus and Folkman ( 1984 ) developed the widely studied transactional framework of stress. This framework holds as a key component the cognitive appraisal process. When individuals perceive factors in the work environment as a threat (i.e., primary appraisal), they will scan the available resources (external or internal to himself or herself) to cope with the stressors (i.e., secondary appraisal). If the coping resources provide minimal relief, strains develop. Until recently, little attention has been given to the cognitive appraisal associated with different work stressors (Dewe & Kompier, 2008 ; Liu & Li, 2017 ). In a study of Polish and Spanish social care service providers, stressors appraised as a threat related positively to burnout and less engagement, but stressors perceived as challenges yielded greater engagement and less burnout (Kożusznik, Rodriguez, & Peiro, 2012 ). Similarly, Dawson et al. ( 2016 ) found that even with support and control resources, hindrance demands were more strain-producing than challenge demands, suggesting that appraisal of the stressor is important. In fact, “many people respond well to challenging work” (Beehr et al., 2001 , p. 126). Kożusznik et al. ( 2012 ) recommend training employees to change the way they view work demands in order to increase engagement, considering that part of the problem may be about how the person appraises his or her environment and, thus, copes with the stressors.

Effort-Reward Imbalance

Siegrist’s ( 1996 ) Model of Effort-Reward Imbalance (ERI) focuses on the notion of social reciprocity, such that a person fulfills required work tasks in exchange for desired rewards (Siegrist, 2010 ). ERI sheds light on how an imbalance in a person’s expectations of an organization’s rewards (e.g., pay, bonus, sense of advancement and development, job security) in exchange for a person’s efforts, that is a break in one’s work contract, leads to negative responses, including long-term ill-health (Siegrist, 2010 ; Siegrist et al., 2014 ). In fact, prolonged perception of a work contract imbalance leads to adverse health, including immunological problems and inflammation, which contribute to cardiovascular disease (Siegrist, 2010 ). The model resembles the relational and interactional psychological contract theory in that it describes an employee’s perception of the terms of the relationship between the person and the workplace, including expectations of performance, job security, training and development opportunities, career progression, salary, and bonuses (Thomas, Au, & Ravlin, 2003 ). The psychological contract, like the ERI model, focuses on social exchange. Furthermore, the psychological contract, like stress theories, are influenced by cultural factors that shape how people interpret their environments (Glazer, 2008 ; Thomas et al., 2003 ). Violations of the psychological contract will negatively affect a person’s attitudes toward the workplace and subsequent health and well-being (Siegrist, 2010 ). To remediate strain, Siegrist ( 2010 ) focuses on both the person and the environment, recognizing that the organization is particularly responsible for changing unfavorable work conditions and the person is responsible for modifying his or her reactions to such conditions.

Stress Management Interventions: Primary, Secondary, and Tertiary

Remediation of work stress and organizational development interventions are about realigning the employee’s experiences in the workplace with factors in the environment, as well as closing the gap between the current environment and the desired environment. Work stress develops when an employee perceives the work demands to exceed the person’s resources to cope and thus threatens employee well-being (Dewe & Kompier, 2008 ). Likewise, an organization’s need to change arises when forces in the environment are creating a need to change in order to survive (see Figure 1 ). Lewin’s ( 1951 ) Force Field Analysis, the foundations of which are in Field Theory, is one of the first organizational development intervention tools presented in the social science literature. The concept behind Force Field Analysis is that in order to survive, organizations must adapt to environmental forces driving a need for organizational change and remove restraining forces that create obstacles to organizational change. In order to do this, management needs to delineate the current field in which the organization is functioning, understand the driving forces for change, identify and dampen or eliminate the restraining forces against change. Several models for analyses may be applied, but most approaches are variations of organizational climate surveys.

Through organizational surveys, workers provide management with a snapshot view of how they perceive aspects of their work environment. Thus, the view of the health of an organization is a function of several factors, chief among them employees’ views (i.e., the climate) about the workplace (Lewin, 1951 ). Indeed, French and Kahn ( 1962 ) posited that well-being depends on the extent to which properties of the person and properties of the environment align in terms of what a person requires and the resources available in a given environment. Therefore, only when properties of the person and properties of the environment are sufficiently understood can plans for change be developed and implemented targeting the environment (e.g., change reporting structures to relieve, and thus prevent future, communication stressors) and/or the person (e.g., providing more autonomy, vacation days, training on new technology). In short, climate survey findings can guide consultants about the emphasis for organizational interventions: before a problem arises aka stress prevention, e.g., carefully crafting job roles), when a problem is present, but steps are taken to mitigate their consequences (aka coping, e.g., providing social support groups), and/or once strains develop (aka. stress management, e.g., healthcare management policies).

For each of the primary (prevention), secondary (coping), and tertiary (stress management) techniques the target for intervention can be the entire workforce, a subset of the workforce, or a specific person. Interventions that target the entire workforce may be considered organizational interventions, as they have direct implications on the health of all individuals and consequently the health of the organization. Several interventions categorized as primary and secondary interventions may also be implemented after strains have developed and after it has been discerned that a person or the organization did not do enough to mitigate stressors or strains (see Figure 1 ). The designation of many of the interventions as belonging to one category or another may be viewed as merely a suggestion.

Primary Interventions (Preventative Stress Management)

Before individuals begin to perceive work-related stressors, organizations engage in stress prevention strategies, such as providing people with resources (e.g., computers, printers, desk space, information about the job role, organizational reporting structures) to do their jobs. However, sometimes the institutional structures and resources are insufficient or ambiguous. Scholars and practitioners have identified several preventative stress management strategies that may be implemented.

Planning and Time Management

When employees feel quantitatively overloaded, sometimes the remedy is improving the employees’ abilities to plan and manage their time (Quick, Quick, Nelson, & Hurrell, 2003 ). Planning is a future-oriented activity that focuses on conceptual and comprehensive work goals. Time management is a behavior that focuses on organizing, prioritizing, and scheduling work activities to achieve short-term goals. Given the purpose of time management, it is considered a primary intervention, as engaging in time management helps to prevent work tasks from mounting and becoming unmanageable, which would subsequently lead to adverse outcomes. Time management comprises three fundamental components: (1) establishing goals, (2) identifying and prioritizing tasks to fulfill the goals, and (3) scheduling and monitoring progress toward goal achievement (Peeters & Rutte, 2005 ). Workers who employ time management have less role ambiguity (Macan, Shahani, Dipboye, & Philips, 1990 ), psychological stress or strain (Adams & Jex, 1999 ; Jex & Elaqua, 1999 ; Macan et al., 1990 ), and greater job satisfaction (Macan, 1994 ). However, Macan ( 1994 ) did not find a relationship between time management and performance. Still, Claessens, van Eerde, Rutte, and Roe ( 2004 ) found that perceived control of time partially mediated the relationships between planning behavior (an indicator of time management), job autonomy, and workload on one hand, and job strains, job satisfaction, and job performance on the other hand. Moreover, Peeters and Rutte ( 2005 ) observed that teachers with high work demands and low autonomy experienced more burnout when they had poor time management skills.

Person-Organization Fit

Just as it is important for organizations to find the right person for the job and organization, so is it the responsibility of a person to choose to work at the right organization—an organization that fulfills the person’s needs and upholds the values important to the individual, as much as the person fulfills the organization’s needs and adapts to its values. When people fit their employing organizations they are setting themselves up for experiencing less strain-producing stressors (Kristof-Brown et al., 2005 ). In a meta-analysis of 62 person-job fit studies and 110 person-organization fit studies, Kristof-Brown et al. ( 2005 ) found that person-job fit had a negative correlation with indicators of job strain. In fact, a primary intervention of career counseling can help to reduce stress levels (Firth-Cozens, 2003 ).

Job Redesign

The Job Demands-Control/Support (JD-C/S), Job Demands-Resources (JD-R), and transactional models all suggest that factors in the work context require modifications in order to reduce potential ill-health and poor organizational performance. Drawing on Hackman and Oldham’s ( 1980 ) Job Characteristics Model, it is possible to assess with the Job Diagnostics Survey (JDS) the current state of work characteristics related to skill variety, task identity, task significance, autonomy, and feedback. Modifying those aspects would help create a sense of meaningfulness, sense of responsibility, and feeling of knowing how one is performing, which subsequently affects a person’s well-being as identified in assessments of motivation, satisfaction, improved performance, and reduced withdrawal intentions and behaviors. Extending this argument to the stress models, it can be deduced that reducing uncertainty or perceived unfairness that may be associated with a person’s perception of these work characteristics, as well as making changes to physical characteristics of the environment (e.g., lighting, seating, desk, air quality), nature of work (e.g., job responsibilities, roles, decision-making latitude), and organizational arrangements (e.g., reporting structure and feedback mechanisms), can help mitigate against numerous ill-health consequences and reduced organizational performance. In fact, Fried et al. ( 2013 ) showed that healthy patients of a medical clinic whose jobs were excessively low (i.e., monotonous) or excessively high (i.e., overstimulating) on job enrichment (as measured by the JDS) had greater abdominal obesity than those whose jobs were optimally enriched. By taking stock of employees’ perceptions of the current work situation, managers might think about ways to enhance employees’ coping toolkit, such as training on how to deal with difficult clients or creating stimulating opportunities when jobs have low levels of enrichment.

Participatory Action Research Interventions

Participatory action research (PAR) is an intervention wherein, through group discussions, employees help to identify and define problems in organizational structure, processes, policies, practices, and reward structures, as well as help to design, implement, and evaluate success of solutions. PAR is in itself an intervention, but its goal is to design interventions to eliminate or reduce work-related factors that are impeding performance and causing people to be unwell. An example of a successful primary intervention, utilizing principles of PAR and driven by the JD-C and JD-C/S stress frameworks is Health Circles (HCs; Aust & Ducki, 2004 ).

HCs, developed in Germany in the 1980s, were popular practices in industries, such as metal, steel, and chemical, and service. Similar to other problem-solving practices, such as quality circles, HCs were based on the assumptions that employees are the experts of their jobs. For this reason, to promote employee well-being, management and administrators solicited suggestions and ideas from the employees to improve occupational health, thereby increasing employees’ job control. HCs also promoted communication between managers and employees, which had a potential to increase social support. With more control and support, employees would experience less strains and better occupational well-being.

Employing the three-steps of (1) problem analysis (i.e., diagnosis or discovery through data generated from organizational records of absenteeism length, frequency, rate, and reason and employee survey), (2) HC meetings (6 to 10 meetings held over several months to brainstorm ideas to improve occupational safety and health concerns identified in the discovery phase), and (3) HC evaluation (to determine if desired changes were accomplished and if employees’ reports of stressors and strains changed after the course of 15 months), improvements were to be expected (Aust & Ducki, 2004 ). Aust and Ducki ( 2004 ) reviewed 11 studies presenting 81 health circles in 30 different organizations. Overall study participants had high satisfaction with the HCs practices. Most companies acted upon employees’ suggestions (e.g., improving driver’s seat and cab, reducing ticket sale during drive, team restructuring and job rotation to facilitate communication, hiring more employees during summer time, and supervisor training program to improve leadership and communication skills) to improve work conditions. Thus, HCs represent a successful theory-grounded intervention to routinely improve employees’ occupational health.

Physical Setting

The physical environment or physical workspace has an enormous impact on individuals’ well-being, attitudes, and interactions with others, as well as on the implications on innovation and well-being (Oksanen & Ståhle, 2013 ; Vischer, 2007 ). In a study of 74 new product development teams (total of 437 study respondents) in Western Europe, Chong, van Eerde, Rutte, and Chai ( 2012 ) found that when teams were faced with challenge time pressures, meaning the teams had a strong interest and desire in tackling complex, but engaging tasks, when they were working proximally close with one another, team communication improved. Chong et al. assert that their finding aligns with prior studies that have shown that physical proximity promotes increased awareness of other team members, greater tendency to initiate conversations, and greater team identification. However, they also found that when faced with hindrance time pressures, physical proximity related to low levels of team communication, but when hindrance time pressure was low, team proximity had an increasingly greater positive relationship with team communication.

In addition to considering the type of work demand teams must address, other physical workspace considerations include whether people need to work collaboratively and synchronously or independently and remotely (or a combination thereof). Consideration needs to be given to how company contributors would satisfy client needs through various modes of communication, such as email vs. telephone, and whether individuals who work by a window might need shading to block bright sunlight from glaring on their computer screens. Finally, people who have to use the telephone for extensive periods of time would benefit from earphones to prevent neck strains. Most physical stressors are rather simple to rectify. However, companies are often not aware of a problem until after a problem arises, such as when a person’s back is strained from trying to move heavy equipment. Companies then implement strategies to remediate the environmental stressor. With the help of human factors, and organizational and office design consultants, many of the physical barriers to optimal performance can be prevented (Rousseau & Aubé, 2010 ). In a study of 215 French-speaking Canadian healthcare employees, Rousseau and Aubé ( 2010 ) found that although supervisor instrumental support positively related with affective commitment to the organization, the relationship was even stronger for those who reported satisfaction with the ambient environment (i.e., temperature, lighting, sound, ventilation, and cleanliness).

Secondary Interventions (Coping)

Secondary interventions, also referred to as coping, focus on resources people can use to mitigate the risk of work-related illness or workplace injury. Resources may include properties related to social resources, behaviors, and cognitive structures. Each of these resource domains may be employed to cope with stressors. Monat and Lazarus ( 1991 ) summarize the definition of coping as “an individual’s efforts to master demands (or conditions of harm, threat, or challenge) that are appraised (or perceived) as exceeding or taxing his or her resources” (p. 5). To master demands requires use of the aforementioned resources. Secondary interventions help employees become aware of the psychological, physical, and behavioral responses that may occur from the stressors presented in their working environment. Secondary interventions help a person detect and attend to stressors and identify resources for and ways of mitigating job strains. Often, coping strategies are learned skills that have a cognitive foundation and serve important functions in improving people’s management of stressors (Lazarus & Folkman, 1991 ). Coping is effortful, but with practice it becomes easier to employ. This idea is the foundation for understanding the role of resilience in coping with stressors. However, “not all adaptive processes are coping. Coping is a subset of adaptational activities that involves effort and does not include everything that we do in relating to the environment” (Lazarus & Folkman, 1991 , p. 198). Furthermore, sometimes to cope with a stressor, a person may call upon social support sources to help with tangible materials or emotional comfort. People call upon support resources because they help to restructure how a person approaches or thinks about the stressor.

Most secondary interventions are aimed at helping the individual, though companies, as a policy, might require all employees to partake in training aimed at increasing employees’ awareness of and skills aimed at handling difficult situations vis à vis company channels (e.g., reporting on sexual harassment or discrimination). Furthermore, organizations might institute mentoring programs or work groups to address various work-related matters. These programs employ awareness-raising activities, stress-education, or skills training (cf., Bhagat, Segovis, & Nelson, 2012 ), which include development of skills in problem-solving, understanding emotion-focused coping, identifying and using social support, and enhancing capacity for resilience. The aim of these programs, therefore, is to help employees proactively review their perceptions of psychological, physical, and behavioral job-related strains, thereby extending their resilience, enabling them to form a personal plan to control stressors and practice coping skills (Cooper, Dewe, & O’Driscoll, 2011 ).

Often these stress management programs are instituted after an organization has observed excessive absenteeism and work-related performance problems and, therefore, are sometimes categorized as a tertiary stress management intervention or even a primary (prevention) intervention. However, the skills developed for coping with stressors also place the programs in secondary stress management interventions. Example programs that are categorized as tertiary or primary stress management interventions may also be secondary stress management interventions (see Figure 1 ), and these include lifestyle advice and planning, stress inoculation training, simple relaxation techniques, meditation, basic trainings in time management, anger management, problem-solving skills, and cognitive-behavioral therapy. Corporate wellness programs also fall under this category. In other words, some programs could be categorized as primary, secondary, or tertiary interventions depending upon when the employee (or organization) identifies the need to implement the program. For example, time management practices could be implemented as a means of preventing some stressors, as a way to cope with mounting stressors, or as a strategy to mitigate symptoms of excessive of stressors. Furthermore, these programs can be administered at the individual level or group level. As related to secondary interventions, these programs provide participants with opportunities to develop and practice skills to cognitively reappraise the stressor(s); to modify their perspectives about stressors; to take time out to breathe, stretch, meditate, relax, and/or exercise in an attempt to support better decision-making; to articulate concerns and call upon support resources; and to know how to say “no” to onslaughts of requests to complete tasks. Participants also learn how to proactively identify coping resources and solve problems.

According to Cooper, Dewe, and O’Driscoll ( 2001 ), secondary interventions are successful in helping employees modify or strengthen their ability to cope with the experience of stressors with the goal of mitigating the potential harm the job stressors may create. Secondary interventions focus on individuals’ transactions with the work environment and emphasize the fit between a person and his or her environment. However, researchers have pointed out that the underlying assumption of secondary interventions is that the responsibility for coping with the stressors of the environment lies within individuals (Quillian-Wolever & Wolever, 2003 ). If companies cannot prevent the stressors in the first place, then they are, in part, responsible for helping individuals develop coping strategies and informing employees about programs that would help them better cope with job stressors so that they are able to fulfill work assignments.

Stress management interventions that help people learn to cope with stressors focus mainly on the goals of enabling problem-resolution or expressing one’s emotions in a healthy manner. These goals are referred to as problem-focused coping and emotion-focused coping (Folkman & Lazarus, 1980 ; Pearlin & Schooler, 1978 ), and the person experiencing the stressors as potential threat is the agent for change and the recipient of the benefits of successful coping (Hobfoll, 1998 ). In addition to problem-focused and emotion-focused coping approaches, social support and resilience may be coping resources. There are many other sources for coping than there is room to present here (see e.g., Cartwright & Cooper, 2005 ); however, the current literature has primarily focused on these resources.

Problem-Focused Coping

Problem-focused or direct coping helps employees remove or reduce stressors in order to reduce their strain experiences (Bhagat et al., 2012 ). In problem-focused coping employees are responsible for working out a strategic plan in order to remove job stressors, such as setting up a set of goals and engaging in behaviors to meet these goals. Problem-focused coping is viewed as an adaptive response, though it can also be maladaptive if it creates more problems down the road, such as procrastinating getting work done or feigning illness to take time off from work. Adaptive problem-focused coping negatively relates to long-term job strains (Higgins & Endler, 1995 ). Discussion on problem-solving coping is framed from an adaptive perspective.

Problem-focused coping is featured as an extension of control, because engaging in problem-focused coping strategies requires a series of acts to keep job stressors under control (Bhagat et al., 2012 ). In the stress literature, there are generally two ways to categorize control: internal versus external locus of control, and primary versus secondary control. Locus of control refers to the extent to which people believe they have control over their own life (Rotter, 1966 ). People high in internal locus of control believe that they can control their own fate whereas people high in external locus of control believe that outside factors determine their life experience (Rotter, 1966 ). Generally, those with an external locus of control are less inclined to engage in problem-focused coping (Strentz & Auerbach, 1988 ). Primary control is the belief that people can directly influence their environment (Alloy & Abramson, 1979 ), and thus they are more likely to engage in problem-focused coping. However, when it is not feasible to exercise primary control, people search for secondary control, with which people try to adapt themselves into the objective environment (Rothbaum, Weisz, & Snyder, 1982 ).

Emotion-Focused Coping

Emotion-focused coping, sometimes referred to as palliative coping, helps employees reduce strains without the removal of job stressors. It involves cognitive or emotional efforts, such as talking about the stressor or distracting oneself from the stressor, in order to lessen emotional distress resulting from job stressors (Bhagat et al., 2012 ). Emotion-focused coping aims to reappraise and modify the perceptions of a situation or seek emotional support from friends or family. These methods do not include efforts to change the work situation or to remove the job stressors (Lazarus & Folkman, 1991 ). People tend to adopt emotion-focused coping strategies when they believe that little or nothing can be done to remove the threatening, harmful, and challenging stressors (Bhagat et al., 2012 ), such as when they are the only individuals to have the skills to get a project done or they are given increased responsibilities because of the unexpected departure of a colleague. Emotion-focused coping strategies include (1) reappraisal of the stressful situation, (2) talking to friends and receiving reassurance from them, (3) focusing on one’s strength rather than weakness, (4) optimistic comparison—comparing one’s situation to others’ or one’s past situation, (5) selective ignoring—paying less attention to the unpleasant aspects of one’s job and being more focused on the positive aspects of the job, (6) restrictive expectations—restricting one’s expectations on job satisfaction but paying more attention to monetary rewards, (7) avoidance coping—not thinking about the problem, leaving the situation, distracting oneself, or using alcohol or drugs (e.g., Billings & Moos, 1981 ).

Some emotion-focused coping strategies are maladaptive. For example, avoidance coping may lead to increased level of job strains in the long run (e.g., Parasuraman & Cleek, 1984 ). Furthermore, a person’s ability to cope with the imbalance of performing work to meet organizational expectations can take a toll on the person’s health, leading to physiological consequences such as cardiovascular disease, sleep disorders, gastrointestinal disorders, and diabetes (Fried et al., 2013 ; Siegrist, 2010 ; Toker, Shirom, Melamed, & Armon, 2012 ; Willert, Thulstrup, Hertz, & Bonde, 2010 ).

Comparing Coping Strategies across Cultures

Most coping research is conducted in individualistic, Western cultures wherein emotional control is emphasized and both problem-solving focused coping and primary control are preferred (Bhagat et al., 2010 ). However, in collectivistic cultures, emotion-focused coping and use of secondary control may be preferred and may not necessarily carry a negative evaluation (Bhagat et al., 2010 ). For example, African Americans are more likely to use emotion-focused coping than non–African Americans (Knight, Silverstein, McCallum, & Fox, 2000 ), and among women who experienced sexual harassment, Anglo American women were less likely to employ emotion focused coping (i.e., avoidance coping) than Turkish women and Hispanic American women, while Hispanic women used more denial than the other two groups (Wasti & Cortina, 2002 ).

Thus, whereas problem-focused coping is venerated in Western societies, emotion-focused coping may be more effective in reducing strains in collectivistic cultures, such as China, Japan, and India (Bhagat et al., 2010 ; Narayanan, Menon, & Spector, 1999 ; Selmer, 2002 ). Indeed, Swedish participants reported more problem-focused coping than did Chinese participants (Xiao, Ottosson, & Carlsson, 2013 ), American college students engaged in more problem-focused coping behaviors than did their Japanese counterparts (Ogawa, 2009 ), and Indian (vs. Canadian) students reported more emotion-focused coping, such as seeking social support and positive reappraisal (Sinha, Willson, & Watson, 2000 ). Moreover, Glazer, Stetz, and Izso ( 2004 ) found that internal locus of control was more predominant in individualistic cultures (United Kingdom and United States), whereas external locus of control was more predominant in communal cultures (Italy and Hungary). Also, internal locus of control was associated with less job stress, but more so for nurses in the United Kingdom and United States than Italy and Hungary. Taken together, adoption of coping strategies and their effectiveness differ significantly across cultures. The extent to which a coping strategy is perceived favorably and thus selected or not selected is not only a function of culture, but also a person’s sociocultural beliefs toward the coping strategy (Morimoto, Shimada, & Ozaki, 2013 ).

Social Support

Social support refers to the aid an entity gives to a person. The source of the support can be a single person, such as a supervisor, coworker, subordinate, family member, friend, or stranger, or an organization as represented by upper-level management representing organizational practices. The type of support can be instrumental or emotional. Instrumental support, including informational support, refers to that which is tangible, such as data to help someone make a decision or colleagues’ sick days so one does not lose vital pay while recovering from illness. Emotional support, including esteem support, refers to the psychological boost given to a person who needs to express emotions and feel empathy from others or to have his or her perspective validated. Beehr and Glazer ( 2001 ) present an overview of the role of social support on the stressor-strain relationship and arguments regarding the role of culture in shaping the utility of different sources and types of support.

Meaningfulness and Resilience

Meaningfulness reflects the extent to which people believe their lives are significant, purposeful, goal-directed, and fulfilling (Glazer, Kożusznik, Meyers, & Ganai, 2014 ). When faced with stressors, people who have a strong sense of meaning in life will also try to make sense of the stressors. Maintaining a positive outlook on life stressors helps to manage emotions, which is helpful in reducing strains, particularly when some stressors cannot be problem-solved (Lazarus & Folkman, 1991 ). Lazarus and Folkman ( 1991 ) emphasize that being able to reframe threatening situations can be just as important in an adaptation as efforts to control the stressors. Having a sense of meaningfulness motivates people to behave in ways that help them overcome stressors. Thus, meaningfulness is often used in the same breath as resilience, because people who are resilient are often protecting that which is meaningful.

Resilience is a personality state that can be fortified and enhanced through varied experiences. People who perceive their lives are meaningful are more likely to find ways to face adversity and are therefore more prone to intensifying their resiliency. When people demonstrate resilience to cope with noxious stressors, their ability to be resilient against other stressors strengthens because through the experience, they develop more competencies (Glazer et al., 2014 ). Thus, fitting with Hobfoll’s ( 1989 , 2001 ) COR theory, meaningfulness and resilience are psychological resources people attempt to conserve and protect, and employ when necessary for making sense of or coping with stressors.

Tertiary Interventions (Stress Management)

Stress management refers to interventions employed to treat and repair harmful repercussions of stressors that were not coped with sufficiently. As Lazarus and Folkman ( 1991 ) noted, not all stressors “are amenable to mastery” (p. 205). Stressors that are unmanageable and lead to strains require interventions to reverse or slow down those effects. Workplace interventions might focus on the person, the organization, or both. Unfortunately, instead of looking at the whole system to include the person and the workplace, most companies focus on the person. Such a focus should not be a surprise given the results of van der Klink, Blonk, Schene, and van Dijk’s ( 2001 ) meta-analysis of 48 experimental studies conducted between 1977 and 1996 . They found that of four types of tertiary interventions, the effect size for cognitive-behavioral interventions and multimodal programs (e.g., the combination of assertive training and time management) was moderate and the effect size for relaxation techniques was small in reducing psychological complaints, but not turnover intention related to work stress. However, the effects of (the five studies that used) organization-focused interventions were not significant. Similarly, Richardson and Rothstein’s ( 2008 ) meta-analytic study, including 36 experimental studies with 55 interventions, showed a larger effect size for cognitive-behavioral interventions than relaxation, organizational, multimodal, or alternative. However, like with van der Klink et al. ( 2001 ), Richardson and Rothstein ( 2008 ) cautioned that there were few organizational intervention studies included and the impact of interventions were determined on the basis of psychological outcomes and not physiological or organizational outcomes. Van der Klink et al. ( 2001 ) further expressed concern that organizational interventions target the workplace and that changes in the individual may take longer to observe than individual interventions aimed directly at the individual.

The long-term benefits of individual focused interventions are not yet clear either. Per Giga, Cooper, and Faragher ( 2003 ), the benefits of person-directed stress management programs will be short-lived if organizational factors to reduce stressors are not addressed too. Indeed, LaMontagne, Keegel, Louie, Ostry, and Landsbergis ( 2007 ), in their meta-analysis of 90 studies on stress management interventions published between 1990 and 2005 , revealed that in relation to interventions targeting organizations only, and interventions targeting individuals only, interventions targeting both organizations and individuals (i.e. the systems approach) had the most favorable positive effects on both the organizations and the individuals. Furthermore, the organization-level interventions were effective at both the individual and organization levels, but the individual-level interventions were effective only at the individual level.

Individual-Focused Stress Management

Individual-focused interventions concentrate on improving conditions for the individual, though counseling programs emphasize that the worker is in charge of reducing “stress,” whereas role-focused interventions emphasize activities that organizations can guide to actually reduce unnecessary noxious environmental factors.

Individual-Focused Stress Management: Employee Assistance Programs

When stress become sufficiently problematic (which is individually gauged or attended to by supportive others) in a worker’s life, employees may utilize the short-term counseling services or referral services Employee Assistance Programs (EAPs) provide. People who utilize the counseling services may engage in cognitive behavioral therapy aimed at changing the way people think about the stressors (e.g., as challenge opportunity over threat) and manage strains. Example topics that may be covered in these therapy sessions include time management and goal setting (prioritization), career planning and development, cognitive restructuring and mindfulness, relaxation, and anger management. In a study of healthcare workers and teachers who participated in a 2-day to 2.5-day comprehensive stress management training program (including 26 topics on identifying, coping with, and managing stressors and strains), Siu, Cooper, and Phillips ( 2013 ) found psychological and physical improvements were self-reported among the healthcare workers (for which there was no control group). However, comparing an intervention group of teachers to a control group of teachers, the extent of change was not as visible, though teachers in the intervention group engaged in more mastery recovery experiences (i.e., they purposefully chose to engage in challenging activities after work).

Individual-Focused Stress Management: Mindfulness

A popular therapy today is to train people to be more mindful, which involves helping people live in the present, reduce negative judgement of current and past experiences, and practicing patience (Birnie, Speca, & Carlson, 2010 ). Mindfulness programs usually include training on relaxation exercises, gentle yoga, and awareness of the body’s senses. In one study offered through the continuing education program at a Canadian university, 104 study participants took part in an 8-week, 90 minute per group (15–20 participants per) session mindfulness program (Birnie et al., 2010 ). In addition to body scanning, they also listened to lectures on incorporating mindfulness into one’s daily life and received a take-home booklet and compact discs that guided participants through the exercises studied in person. Two weeks after completing the program, participants’ mindfulness attendance and general positive moods increased, while physical, psychological, and behavioral strains decreased. In another study on a sample of U.K. government employees, study participants receiving three sessions of 2.5 to 3 hours each training on mindfulness, with the first two sessions occurring in consecutive weeks and the third occurring about three months later, Flaxman and Bond ( 2010 ) found that compared to the control group, the intervention group showed a decrease in distress levels from Time 1 (baseline) to Time 2 (three months after first two training sessions) and Time 1 to Time 3 (after final training session). Moreover, of the mindfulness intervention study participants who were clinically distressed, 69% experienced clinical improvement in their psychological health.

Individual-Focused Stress Management: Biofeedback/Imagery/Meditation/Deep Breathing

Biofeedback uses electronic equipment to inform users about how their body is responding to tension. With guidance from a therapist, individuals then learn to change their physiological responses so that their pulse normalizes and muscles relax (Norris, Fahrion, & Oikawa, 2007 ). The therapist’s guidance might include reminders for imagery, meditation, body scan relaxation, and deep breathing. Saunders, Driskell, Johnston, and Salas’s ( 1996 ) meta-analysis of 37 studies found that imagery helped reduce state and performance anxiety. Once people have been trained to relax, reminder triggers may be sent through smartphone push notifications (Villani et al., 2013 ).

Smartphone technology can also be used to support weight loss programs, smoking cessation programs, and medication or disease (e.g., diabetes) management compliance (Heron & Smyth, 2010 ; Kannampallil, Waicekauskas, Morrow, Kopren, & Fu, 2013 ). For example, smartphones could remind a person to take medications or test blood sugar levels or send messages about healthy behaviors and positive affirmations.

Individual-Focused Stress Management: Sleep/Rest/Respite

Workers today sleep less per night than adults did nearly 30 years ago (Luckhaupt, Tak, & Calvert, 2010 ; National Sleep Foundation, 2005 , 2013 ). In order to combat problems, such as increased anxiety and cardiovascular artery disease, associated with sleep deprivation and insufficient rest, it is imperative that people disconnect from their work at least one day per week or preferably for several weeks so that they are able to restore psychological health (Etzion, Eden, & Lapidot, 1998 ; Ragsdale, Beehr, Grebner, & Han, 2011 ). When college students engaged in relaxation-type activities, such as reading or watching television, over the weekend, they experienced less emotional exhaustion and greater general well-being than students who engaged in resources-consuming activities, such as house cleaning (Ragsdale et al., 2011 ). Additional research and future directions for research are reviewed and identified in the work of Sonnentag ( 2012 ). For example, she asks whether lack of ability to detach from work is problematic for people who find their work meaningful. In other words, are negative health consequences only among those who do not take pleasure in their work? Sonnetag also asks how teleworkers detach from their work when engaging in work from the home. Ironically, one of the ways that companies are trying to help with the challenges of high workload or increased need to be available to colleagues, clients, or vendors around the globe is by offering flexible work arrangements, whereby employees who can work from home are given the opportunity to do so. Companies that require global interactions 24-hours per day often employ this strategy, but is the solution also a source of strain (Glazer, Kożusznik, & Shargo, 2012 )?

Individual-Focused Stress Management: Role Analysis

Role analysis or role clarification aims to redefine, expressly identify, and align employees’ roles and responsibilities with their work goals. Through role negotiation, involved parties begin to develop a new formal or informal contract about expectations and define resources needed to fulfill those expectations. Glazer has used this approach in organizational consulting and, with one memorable client engagement, found that not only were the individuals whose roles required deeper re-evaluation happier at work (six months later), but so were their subordinates. Subordinates who once characterized the two partners as hostile and akin to a couple going through a bad divorce, later referred to them as a blissful pair. Schaubroeck, Ganster, Sime, and Ditman ( 1993 ) also found in a three-wave study over a two-year period that university employees’ reports of role clarity and greater satisfaction with their supervisor increased after a role clarification exercise of top managers’ roles and subordinates’ roles. However, the intervention did not have any impact on reported physical symptoms, absenteeism, or psychological well-being. Role analysis is categorized under individual-focused stress management intervention because it is usually implemented after individuals or teams begin to demonstrate poor performance and because the intervention typically focuses on a few individuals rather than an entire organization or group. In other words, the intervention treats the person’s symptoms by redefining the role so as to eliminate the stimulant causing the problem.

Organization-Focused Stress Management

At the organizational level, companies that face major declines in productivity and profitability or increased costs related to healthcare and disability might be motivated to reassess organizational factors that might be impinging on employees’ health and well-being. After all, without healthy workers, it is not possible to have a healthy organization. Companies may choose to implement practices and policies that are expected to help not only the employees, but also the organization with reduced costs associated with employee ill-health, such as medical insurance, disability payments, and unused office space. Example practices and policies that may be implemented include flexible work arrangements to ensure that employees are not on the streets in the middle of the night for work that can be done from anywhere (such as the home), diversity programs to reduce stress-induced animosity and prejudice toward others, providing only healthy food choices in cafeterias, mandating that all employees have physicals in order to receive reduced prices for insurance, company-wide closures or mandatory paid time off, and changes in organizational visioning.

Organization-Focused Stress Management: Organizational-Level Occupational Health Interventions

As with job design interventions that are implemented to remediate work characteristics that were a source of unnecessary or excessive stressors, so are organizational-level occupational health (OLOH) interventions. As with many of the interventions, its placement as a primary or tertiary stress management intervention may seem arbitrary, but when considering the goal and target of change, it is clear that the intervention is implemented in response to some ailing organizational issues that need to be reversed or stopped, and because it brings in the entire organization’s workforce to address the problems, it has been placed in this category. There are several more case studies than empirical studies on the topic of whole system organizational change efforts (see example case studies presented by the United Kingdom’s Health and Safety Executive). It is possible that lack of published empirical work is not so much due to lack of attempting to gather and evaluate the data for publication, but rather because the OLOH interventions themselves never made it to the intervention stage, the interventions failed (Biron, Gatrell, & Cooper, 2010 ), or the level of evaluation was not rigorous enough to get into empirical peer-review journals. Fortunately, case studies provide some indication of the opportunities and problems associated with OLOH interventions.

One case study regarding Cardiff and Value University Health Board revealed that through focus group meetings with members of a steering group (including high-level managers and supported by top management) and facilitated by a neutral, non-judgemental organizational health consultant, ideas for change were posted on newsprint, discussed, and areas in the organization needing change were identified. The intervention for giving voice to people who initially had little already had a positive effect on the organization, as absence decreased by 2.09% and 6.9% merely 12 and 18 months, respectively, after the intervention. Translated in financial terms, the 6.9% change was equivalent to a quarterly savings of £80,000 (Health & Safety Executive, n.d. ). Thus, focusing on the context of change and how people will be involved in the change process probably helped the organization realize improvements (Biron et al., 2010 ). In a recent and rare empirical study, employing both qualitative and quantitative data collection methods, Sørensen and Holman ( 2014 ) utilized PAR in order to plan and implement an OLOH intervention over the course of 14 months. Their study aimed to examine the effectiveness of the PAR process in reducing workers’ work-related and social or interpersonal-related stressors that derive from the workplace and improving psychological, behavioral, and physiological well-being across six Danish organizations. Based on group dialogue, 30 proposals for change were proposed, all of which could be categorized as either interventions to focus on relational factors (e.g., management feedback improvement, engagement) or work processes (e.g., reduced interruptions, workload, reinforcing creativity). Of the interventions that were implemented, results showed improvements on manager relationship quality and reduced burnout, but no changes with respect to work processes (i.e., workload and work pace) perhaps because the employees already had sufficient task control and variety. These findings support Dewe and Kompier’s ( 2008 ) position that occupational health can be reinforced through organizational policies that reinforce quality jobs and work experiences.

Organization-Focused Stress Management: Flexible Work Arrangements

Dewe and Kompier ( 2008 ), citing the work of Isles ( 2005 ), noted that concern over losing one’s job is a reason for why 40% of survey respondents indicated they work more hours than formally required. In an attempt to create balance and perceived fairness in one’s compensation for putting in extra work hours, employees will sometimes be legitimately or illegitimately absent. As companies become increasingly global, many people with desk jobs are finding themselves communicating with colleagues who are halfway around the globe and at all hours of the day or night (Glazer et al., 2012 ). To help minimize the strains associated with these stressors, companies might devise flexible work arrangements (FWA), though the type of FWA needs to be tailored to the cultural environment (Masuda et al., 2012 ). FWAs give employees some leverage to decide what would be the optimal work arrangement for them (e.g., part-time, flexible work hours, compressed work week, telecommuting). In other words, FWA provides employees with the choice of when to work, where to work (on-site or off-site), and how many hours to work in a day, week, or pay period (Kossek, Thompson, & Lautsch, 2015 ). However, not all employees of an organization have equal access to or equitable use of FWAs; workers in low-wage, hourly jobs are often beholden to being physically present during specific hours (Swanberg McKechnie, Ojha, & James, 2011 ). In a study of over 1,300 full-time hourly retail employees in the United States, Swanberg et al. ( 2011 ) showed that employees who have control over their work schedules and over their work hours were satisfied with their work schedules, perceived support from the supervisor, and work engagement.

Unfortunately, not all FWAs yield successful results for the individual or the organization. Being able to work from home or part-time can have problems too, as a person finds himself or herself working more hours from home than required. Sometimes telecommuting creates work-family conflict too as a person struggles to balance work and family obligations while working from home. Other drawbacks include reduced face-to-face contact between work colleagues and stakeholders, challenges shaping one’s career growth due to limited contact, perceived inequity if some have more flexibility than others, and ambiguity about work role processes for interacting with employees utilizing the FWA (Kossek et al., 2015 ). Organizations that institute FWAs must carefully weigh the benefits and drawbacks the flexibility may have on the employees using it or the employees affected by others using it, as well as the implications on the organization, including the vendors who are serving and clients served by the organization.

Organization-Focused Stress Management: Diversity Programs

Employees in the workplace might experience strain due to feelings of discrimination or prejudice. Organizational climates that do not promote diversity (in terms of age, religion, physical abilities, ethnicity, nationality, sex, and other characteristics) are breeding grounds for undesirable attitudes toward the workplace, lower performance, and greater turnover intention (Bergman, Palmieri, Drasgow, & Ormerod, 2012 ; Velez, Moradi, & Brewster, 2013 ). Management is thus advised to implement programs that reinforce the value and importance of diversity, as well as manage diversity to reduce conflict and feelings of prejudice. In fact, managers who attended a leadership training program reported higher multicultural competence in dealing with stressful situations (Chrobot-Mason & Leslie, 2012 ), and managers who persevered through challenges were more dedicated to coping with difficult diversity issues (Cilliers, 2011 ). Thus, diversity programs can help to reduce strains by directly reducing stressors associated with conflict linked to diversity in the workplace and by building managers’ resilience.

Organization-Focused Stress Management: Healthcare Management Policies

Over the past few years, organizations have adopted insurance plans that implement wellness programs for the sake of managing the increasing cost of healthcare that is believed to be a result of individuals’ not managing their own health, with regular check-ups and treatment. The wellness programs require all insured employees to visit a primary care provider, complete a health risk assessment, and engage in disease management activities as specified by a physician (e.g., see frequently asked questions regarding the State of Maryland’s Wellness Program). Companies believe that requiring compliance will reduce health problems, although there is no proof that such programs save money or that people would comply. One study that does, however, boast success, was a 12-week workplace health promotion program aimed at reducing Houston airport workers’ weight (Ebunlomo, Hare-Everline, Weber, & Rich, 2015 ). The program, which included 235 volunteer participants, was deemed a success, as there was a total weight loss of 345 pounds (or 1.5 lbs per person). Given such results in Houston, it is clear why some people are also skeptical over the likely success of wellness programs, particularly as there is no clear method for evaluating their efficacy (Sinnott & Vatz, 2015 ).

Moreover, for some, such a program is too paternalistic and intrusive, as well as punishes anyone who chooses not to actively participate in disease management programs (Sinnott & Vatz, 2015 ). The programs put the onus of change on the person, though it is a response to the high costs of ill-health. The programs neglect to consider the role of the organization in reducing the barriers to healthy lifestyle, such as cloaking exempt employment as simply needing to get the work done, when it usually means working significantly more hours than a standard workweek. In fact, workplace health promotion programs did not reduce presenteeism (i.e., people going to work while unwell thereby reducing their job performance) among those who suffered from physical pain (Cancelliere, Cassidy, Ammendolia, & Côte, 2011 ). However, supervisor education, worksite exercise, lifestyle intervention through email, midday respite from repetitive work, a global stress management program, changes in lighting, and telephone interventions helped to reduce presenteeism. Thus, emphasis needs to be placed on psychosocial aspects of the organization’s structure, including managers and overall organizational climate for on-site presence, that reinforces such behavior (Cancelliere et al., 2011 ). Moreover, wellness programs are only as good as the interventions to reduce work-related stressors and improve organizational resources to enable workers to improve their overall psychological and physical health.

Concluding Remarks

Future research.

One of the areas requiring more theoretical and practical attention is that of the utility of stress frameworks to guide organizational development change interventions. Although it has been proposed that the foundation for work stress management interventions is in organizational development, and even though scholars and practitioners of organization development were also founders of research programs that focused on employee health and well-being or work stress, there are few studies or other theoretical works that link the two bodies of literature.

A second area that requires additional attention is the efficacy of stress management interventions across cultures. In examining secondary stress management interventions (i.e., coping), some cross-cultural differences in findings were described; however, there is still a dearth of literature from different countries on the utility of different prevention, coping, and stress management strategies.

A third area that has been blossoming since the start of the 21st century is the topic of hindrance and challenge stressors and the implications of both on workers’ well-being and performance. More research is needed on this topic in several areas. First, there is little consistency by which researchers label a stressor as a hindrance or a challenge. Researchers sometimes take liberties with labels, but it is not the researchers who should label a stressor but the study participants themselves who should indicate if a stressor is a source of strain. Rodríguez, Kozusznik, and Peiró ( 2013 ) developed a measure in which respondents indicate whether a stressor is a challenge or a hindrance. Just as some people may perceive demands to be challenges that they savor and that result in a psychological state of eustress (Nelson & Simmons, 2003 ), others find them to be constraints that impede goal fulfillment and thus might experience distress. Likewise, some people might perceive ambiguity as a challenge that can be overcome and others as a constraint over which he or she has little control and few or no resources with which to cope. More research on validating the measurement of challenge vs. hindrance stressors, as well as eustress vs. distress, and savoring vs. coping, is warranted. Second, at what point are challenge stressors harmful? Just because people experiencing challenge stressors continue to perform well, it does not necessarily mean that they are healthy people. A great deal of stressors are intellectually stimulating, but excessive stimulation can also take a toll on one’s physiological well-being, as evident by the droves of professionals experiencing different kinds of diseases not experienced as much a few decades ago, such as obesity (Fried et al., 2013 ). Third, which stress management interventions would better serve to reduce hindrance stressors or to reduce strain that may result from challenge stressors while reinforcing engagement-producing challenge stressors?

A fourth area that requires additional attention is that of the flexible work arrangements (FWAs). One of the reasons companies have been willing to permit employees to work from home is not so much out of concern for the employee, but out of the company’s need for the focal person to be able to communicate with a colleague working from a geographic region when it is night or early morning for the focal person. Glazer, Kożusznik, and Shargo ( 2012 ) presented several areas for future research on this topic, noting that by participating on global virtual teams, workers face additional stressors, even while given flexibility of workplace and work time. As noted earlier, more research needs to be done on the extent to which people who take advantage of FWAs are advantaged in terms of detachment from work. Can people working from home detach? Are those who find their work invigorating also likely to experience ill-health by not detaching from work?

A fifth area worthy of further research attention is workplace wellness programing. According to Page and Vella-Brodrick ( 2009 ), “subjective and psychological well-being [are] key criteria for employee mental health” (p. 442), whereby mental health focuses on wellness, rather than the absence of illness. They assert that by fostering employee mental health, organizations are supporting performance and retention. Employee well-being can be supported by ensuring that jobs are interesting and meaningful, goals are achievable, employees have control over their work, and skills are used to support organizational and individual goals (Dewe & Kompier, 2008 ). However, just as mental health is not the absence of illness, work stress is not indicative of an absence of psychological well-being. Given the perspective that employee well-being is a state of mind (Page & Vella-Brodrick, 2009 ), we suggest that employee well-being can be negatively affected by noxious job stressors that cannot be remediated, but when job stressors are preventable, employee well-being can serve to protect an employee who faces job stressors. Thus, wellness programs ought to focus on providing positive experiences by enhancing and promoting health, as well as building individual resources. These programs are termed “green cape” interventions (Pawelski, 2016 ). For example, with the growing interests in positive psychology, researchers and practitioners have suggested employing several positive psychology interventions, such as expressing gratitude, savoring experiences, and identifying one’s strengths (Tetrick & Winslow, 2015 ). Another stream of positive psychology is psychological capital, which includes four malleable functions of self-efficacy, optimism, hope, and resilience (Luthans, Youssef, & Avolio, 2007 ). Workplace interventions should include both “red cape” interventions (i.e., interventions to reduce negative experiences) and “green cape” interventions (i.e., workplace wellness programs; Polly, 2014 ).

A Healthy Organization’s Pledge

A healthy workplace requires healthy workers. Period. Among all organizations’ missions should be the focus on a healthy workforce. To maintain a healthy workforce, the company must routinely examine its own contributions in terms of how it structures itself; reinforces communications among employees, vendors, and clients; how it rewards and cares for its people (e.g., ensuring they get sufficient rest and can detach from work); and the extent to which people at the upper levels are truly connected with the people at the lower levels. As a matter of practice, management must recognize when employees are overworked, unwell, and poorly engaged. Management must also take stock of when it is doing well and right by its contributors’ and maintain and reinforce the good practices, norms, and procedures. People in the workplace make the rules; people in the workplace can change the rules. How management sees its employees and values their contribution will have a huge role in how a company takes stock of its own pain points. Providing employees with tools to manage their own reactions to work-related stressors and consequent strains is fine, but wouldn’t it be grand if organizations took better notice about what they could do to mitigate the strain-producing stressors in the first place and take ownership over how employees are treated?

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Stress and Well-Being: A Systematic Case Study of Adolescents’ Experiences in a Mindfulness-Based Program

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• Volume 30 , pages 431–446, ( 2021 )

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• Deborah L. Schussler   ORCID: orcid.org/0000-0001-5970-4326 1 ,
• Yoonkyung Oh 2 ,
• Julia Mahfouz 3 ,
• Joseph Levitan 4 ,
• Jennifer L. Frank 1 ,
• Patricia C. Broderick 1 ,
• Joy L. Mitra 1 ,
• Elaine Berrena 1 ,
• Kimberly Kohler 1 &
• Mark T. Greenberg 1  

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Research on mindfulness-based programs (MBPs) for adolescents suggests improvements in stress, emotion regulation, and ability to perform some cognitive tasks. However, there is little research examining the contextual factors impacting why specific students experience particular changes and the process by which these changes occur. Responding to the NIH call for “n-of-1 studies” that examine how individuals respond to interventions, we conducted a systematic case study, following an intervention trial (Learning to BREATHE), to investigate how individual students experienced an MBP. Specifically, we examined how students’ participation impacted their perceived stress and well-being and why students chose to implement practices in their daily lives. Students in health classes at two diverse high schools completed quantitative self-report measures (pre-, post-, follow-up), qualitative interviews, and open-ended survey questions. We analyzed self-report data to examine whether and to what extent student performance on measures of psychological functioning, stress, attention, and well-being changed before and after participation in an MBP. We analyzed qualitative data to investigate contextual information about why those changes may have occurred and why individuals chose to adopt or disregard mindfulness practices outside the classroom. Results suggest that, particularly for high-risk adolescents and those who integrated program practices into their daily lives, the intervention impacted internalizing symptoms, stress management, mindfulness, and emotion regulation. Mindful breathing was found to be a feasible practice easily incorporated into school routines. Contextual factors impacted practice uptake and program outcomes. Implications for practitioners aiming to help high school students manage stress are discussed.

Systematic case study provides nuanced data about how individuals respond to a mindfulness-based program (MBP).

High-risk adolescents received the most benefit from MBP participation.

Students who practiced were more likely to experience change across outcomes.

The MBP most impacted the way students responded to stress.

Mindful breathing may be the most accessible practice for students.

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Author Contributions

All authors contributed to the study conception and design. Qualitative data collection and analysis were performed by D.L.S., J.M., and J.L. Quantitative analysis was performed by Y.O., while J.L.M., E.B., and K.K. led the quantitative data collection. The first draft of the manuscript was written by D.L.S. and Y.O., and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

The project described was supported by Award Number R305A140113 from the Institute of Education Sciences (IES). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Institute of Education Sciences or the U.S. Department of Education.

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Schussler, D.L., Oh, Y., Mahfouz, J. et al. Stress and Well-Being: A Systematic Case Study of Adolescents’ Experiences in a Mindfulness-Based Program. J Child Fam Stud 30 , 431–446 (2021). https://doi.org/10.1007/s10826-020-01864-5

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Revealing the Hidden Consequences: Real-life Case Studies in Stress and Anxiety

In today's fast-paced world, stress and anxiety are part and parcel of everyday life. While they are natural reactions to challenging circumstances, persistent, poorly managed stress can result in serious health outcomes. The stress behind the development of these illnesses is often not seen or well-treated since it is invisible and doesn't show up on x-rays or lab tests.

Case Study 1: The Physical Toll of Chronic Stress and Anxiety

John, a middle-aged executive, experienced chronic stress due to work and family pressure, leading to a range of health issues. Having never learned good stress management skills, John overate, drank too much coffee in the daytime and alcohol in the evening, and made no time for exercise or relaxation in his overbusy days. 

He didn’t complain or even recognize how stressed he was since all his colleagues and friends seemed to be dealing with the same issues.  He didn't recognize the signs of stress but over a few years accumulated a number of medical diagnoses and medications to go with them.

• Eating on the run and too much coffee and alcohol gave him chronic heartburn, diagnosed as “GERD” (GastroEsophageal Reflux Disease) and treated with omeprazole and antacids
• John developed high blood pressure and high cholesterol, putting him at high risk for heart disease and stroke, so was given blood pressure medications and statin medication
• His increasingly poor sleep was treated with Trazodone, a medication that knocked him out but left him feeling groggy and starting his day with 2 or 3 large cups of coffee
• As he became increasingly exhausted and using more alcohol, he got crankier and more irritable, early signs of depression in men. His doctor started him on an antidepressant which helped his mood, but didn't help him change his lifestyle which was at the root of all these “diagnoses.”

Case Study 2: Mental and Emotional Consequences

Susan, a school teacher, faced constant anxiety due to high workload and financial problems. This prolonged exposure to unmanaged stress and anxiety led to:

• Emotional Burnout: Over time, Susan experienced emotional exhaustion leading to feelings of detachment, a condition often referred to as burnout.
• Cognitive Difficulties: Chronic stress and burnout affected her ability to concentrate, plan, and make good decisions.
• Depression: Eventually, persistent stress and anxiety triggered the onset of depression in Susan

Case Study 3: The Social Impact

Emma, a college student suffering from chronic stress, worry, and anxiety, exhibited changes in her social behavior:

• Isolation: She started withdrawing from her friends and social activities, leading to feelings of loneliness and even more stress.
• Conflict: Her stress made her irritable, leading to increased conflict in her personal relationships, worsening her isolation and loneliness.

Identifying these signs of too much stress is the first step towards recovery. None of these people had an illness or disease – they were overstressed and didn't have the tools or support to help them manage it.  There are many techniques and tools that can help to keep stress and anxiety at manageable levels:

• Mindfulness and Meditation: Techniques like these helped John stay focused on the present moment, reducing his stress levels.
• Physical Activity: Regular exercise assisted Susan in reducing her stress. It served as a natural mood enhancer and distracted her from constant worry.
• Balanced Diet: Emma found that a healthy diet helped combat her stress. Certain foods even assisted in reducing stress, such as those rich in omega-3 fatty acids and vitamin C.
• Guided Imagery: Upon recognizing the detrimental effects of stress and anxiety on their daily lives, John, Susan, and Emma decided to learn how to reduce stress and manage it better when it couldn’t be avoided.  Either on their own or with the urging of a therapist, they discovered relaxation and guided imagery. The skills and practices they learned became a keystone of their healthy lifestyle, playing a significant role in alleviating their stress and anxiety and guiding them towards recovery.

Recognizing the signs of excessive stress and anxiety is the first step towards effectively managing them. Learning good elf-care stress and anxiety reduction skills is the second step. If you’re too overwhelmed or mired down in the stress, professional help you dig out of it. Remember, seeking help and making strides towards a healthier life is absolutely okay. Living a life free from the burden of constant worry is your right. The journey to that life begins now.

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The Worry Solution

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Stress: A Case Study

Read the story of a women who thought she was having a heart attack, but was instead diagnosed with panic disorder, panic attacks.

Although on the surface everything seemed fine, she felt that, "the wheels on my tricycle are about to fall off. I'm a mess." Over the past several months she had attacks of shortness of breath, heart palpitations, chest pains, dizziness, and tingling sensations in her fingers and toes. Filled with a sense of impending doom, she would become anxious to the point of panic. Every day she awoke with a dreaded feeling that an attack might strike without reason or warning.

On two occasions, she rushed to a nearby hospital emergency room fearing she was having a heart attack. The first episode followed an argument with her boyfriend about the future of their relationship. After studying her electrocardiogram, the emergency room doctor told her she was "just hyperventilating" and showed her how to breathe into a paper bag to handle the situation in the future. She felt foolish and went home embarrassed, angry and confused. She remained convinced that she had almost had a heart attack.

Her next severe attack occurred after a fight at work with her boss over a new marketing campaign. This time she insisted that she be hospitalized overnight for extensive diagnostic tests and that her internist be consulted. The results were the same--no heart attack. Her internist prescribed a tranquilizer to calm her down.

Convinced now that her own doctor was wrong, she sought the advice of a cardiologist, who conducted another battery of tests, again with no physical findings. The doctor concluded that stress was the primary cause of the panic attacks and "heart attack" symptoms. The doctor referred her to psychologist specializing in stress.

During her first visit, professionals administered stress tests and explained how stress could cause her physical symptoms. At her next visit, utilizing the tests results, they described to her the sources and nature of her health problems. The tests revealed that she was highly susceptible to stress, that she was enduring enormous stress from her family, her personal life, and her job, and that she was experiencing a number of stress-related symptoms in her emotional, sympathetic nervous, muscular and endocrine systems. She wasn't sleeping or eating well, didn't exercise, abused caffeine and alcohol, and lived on the edge financially.

The stress testing crystallized how susceptible she was to stress, what was causing her stress, and how stress was expressing itself in her "heart attack" and other symptoms. This newly found knowledge eliminated a lot of her confusion and separated her concerns into simpler, more manageable problems.

She realized that she was feeling tremendous pressure from her boyfriend, as well as her mother to settle down and get married; yet, she didn't feel ready. At the same time, work was overwhelming her as a new marketing campaign began. Any serious emotional incident--a quarrel with her boyfriend or her boss--sent her over the edge. Her body's response was hyperventilation, palpitations, chest pain, dizziness, anxiety, and a dreadful sense of doom. Stress, in short, was destroying her life.

Adapted from The Stress Solution by Lyle H. Miller, Ph.D., and Alma Dell Smith, Ph.D.

next: Terrorism Fear: What You Can Do To Alleviate It ~ anxiety-panic library articles ~ all anxiety disorders articles

APA Reference Staff, H. (2007, February 18). Stress: A Case Study, HealthyPlace. Retrieved on 2024, April 19 from https://www.healthyplace.com/anxiety-panic/articles/stress-a-case-study

Medically reviewed by Harry Croft, MD

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What Is a Case Study?

Weighing the pros and cons of this method of research

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

Where do you find data for a case study, how do i write a psychology case study.

A case study is an in-depth study of one person, group, or event. In a case study, nearly every aspect of the subject's life and history is analyzed to seek patterns and causes of behavior. Case studies can be used in many different fields, including psychology, medicine, education, anthropology, political science, and social work.

The point of a case study is to learn as much as possible about an individual or group so that the information can be generalized to many others. Unfortunately, case studies tend to be highly subjective, and it is sometimes difficult to generalize results to a larger population.

While case studies focus on a single individual or group, they follow a format similar to other types of psychology writing. If you are writing a case study, we got you—here are some rules of APA format to reference.  

At a Glance

A case study, or an in-depth study of a person, group, or event, can be a useful research tool when used wisely. In many cases, case studies are best used in situations where it would be difficult or impossible for you to conduct an experiment. They are helpful for looking at unique situations and allow researchers to gather a lot of˜ information about a specific individual or group of people. However, it's important to be cautious of any bias we draw from them as they are highly subjective.

What Are the Benefits and Limitations of Case Studies?

A case study can have its strengths and weaknesses. Researchers must consider these pros and cons before deciding if this type of study is appropriate for their needs.

One of the greatest advantages of a case study is that it allows researchers to investigate things that are often difficult or impossible to replicate in a lab. Some other benefits of a case study:

• Allows researchers to capture information on the 'how,' 'what,' and 'why,' of something that's implemented
• Gives researchers the chance to collect information on why one strategy might be chosen over another
• Permits researchers to develop hypotheses that can be explored in experimental research

On the other hand, a case study can have some drawbacks:

• It cannot necessarily be generalized to the larger population
• Cannot demonstrate cause and effect
• It may not be scientifically rigorous
• It can lead to bias

Researchers may choose to perform a case study if they want to explore a unique or recently discovered phenomenon. Through their insights, researchers develop additional ideas and study questions that might be explored in future studies.

It's important to remember that the insights from case studies cannot be used to determine cause-and-effect relationships between variables. However, case studies may be used to develop hypotheses that can then be addressed in experimental research.

Case Study Examples

There have been a number of notable case studies in the history of psychology. Much of  Freud's work and theories were developed through individual case studies. Some great examples of case studies in psychology include:

• Anna O : Anna O. was a pseudonym of a woman named Bertha Pappenheim, a patient of a physician named Josef Breuer. While she was never a patient of Freud's, Freud and Breuer discussed her case extensively. The woman was experiencing symptoms of a condition that was then known as hysteria and found that talking about her problems helped relieve her symptoms. Her case played an important part in the development of talk therapy as an approach to mental health treatment.
• Phineas Gage : Phineas Gage was a railroad employee who experienced a terrible accident in which an explosion sent a metal rod through his skull, damaging important portions of his brain. Gage recovered from his accident but was left with serious changes in both personality and behavior.
• Genie : Genie was a young girl subjected to horrific abuse and isolation. The case study of Genie allowed researchers to study whether language learning was possible, even after missing critical periods for language development. Her case also served as an example of how scientific research may interfere with treatment and lead to further abuse of vulnerable individuals.

Such cases demonstrate how case research can be used to study things that researchers could not replicate in experimental settings. In Genie's case, her horrific abuse denied her the opportunity to learn a language at critical points in her development.

This is clearly not something researchers could ethically replicate, but conducting a case study on Genie allowed researchers to study phenomena that are otherwise impossible to reproduce.

There are a few different types of case studies that psychologists and other researchers might use:

• Collective case studies : These involve studying a group of individuals. Researchers might study a group of people in a certain setting or look at an entire community. For example, psychologists might explore how access to resources in a community has affected the collective mental well-being of those who live there.
• Descriptive case studies : These involve starting with a descriptive theory. The subjects are then observed, and the information gathered is compared to the pre-existing theory.
• Explanatory case studies : These   are often used to do causal investigations. In other words, researchers are interested in looking at factors that may have caused certain things to occur.
• Exploratory case studies : These are sometimes used as a prelude to further, more in-depth research. This allows researchers to gather more information before developing their research questions and hypotheses .
• Instrumental case studies : These occur when the individual or group allows researchers to understand more than what is initially obvious to observers.
• Intrinsic case studies : This type of case study is when the researcher has a personal interest in the case. Jean Piaget's observations of his own children are good examples of how an intrinsic case study can contribute to the development of a psychological theory.

The three main case study types often used are intrinsic, instrumental, and collective. Intrinsic case studies are useful for learning about unique cases. Instrumental case studies help look at an individual to learn more about a broader issue. A collective case study can be useful for looking at several cases simultaneously.

The type of case study that psychology researchers use depends on the unique characteristics of the situation and the case itself.

There are a number of different sources and methods that researchers can use to gather information about an individual or group. Six major sources that have been identified by researchers are:

• Archival records : Census records, survey records, and name lists are examples of archival records.
• Direct observation : This strategy involves observing the subject, often in a natural setting . While an individual observer is sometimes used, it is more common to utilize a group of observers.
• Documents : Letters, newspaper articles, administrative records, etc., are the types of documents often used as sources.
• Interviews : Interviews are one of the most important methods for gathering information in case studies. An interview can involve structured survey questions or more open-ended questions.
• Participant observation : When the researcher serves as a participant in events and observes the actions and outcomes, it is called participant observation.
• Physical artifacts : Tools, objects, instruments, and other artifacts are often observed during a direct observation of the subject.

If you have been directed to write a case study for a psychology course, be sure to check with your instructor for any specific guidelines you need to follow. If you are writing your case study for a professional publication, check with the publisher for their specific guidelines for submitting a case study.

Here is a general outline of what should be included in a case study.

Section 1: A Case History

This section will have the following structure and content:

Background information : The first section of your paper will present your client's background. Include factors such as age, gender, work, health status, family mental health history, family and social relationships, drug and alcohol history, life difficulties, goals, and coping skills and weaknesses.

Description of the presenting problem : In the next section of your case study, you will describe the problem or symptoms that the client presented with.

Describe any physical, emotional, or sensory symptoms reported by the client. Thoughts, feelings, and perceptions related to the symptoms should also be noted. Any screening or diagnostic assessments that are used should also be described in detail and all scores reported.

Your diagnosis : Provide your diagnosis and give the appropriate Diagnostic and Statistical Manual code. Explain how you reached your diagnosis, how the client's symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis.

Section 2: Treatment Plan

This portion of the paper will address the chosen treatment for the condition. This might also include the theoretical basis for the chosen treatment or any other evidence that might exist to support why this approach was chosen.

• Cognitive behavioral approach : Explain how a cognitive behavioral therapist would approach treatment. Offer background information on cognitive behavioral therapy and describe the treatment sessions, client response, and outcome of this type of treatment. Make note of any difficulties or successes encountered by your client during treatment.
• Humanistic approach : Describe a humanistic approach that could be used to treat your client, such as client-centered therapy . Provide information on the type of treatment you chose, the client's reaction to the treatment, and the end result of this approach. Explain why the treatment was successful or unsuccessful.
• Psychoanalytic approach : Describe how a psychoanalytic therapist would view the client's problem. Provide some background on the psychoanalytic approach and cite relevant references. Explain how psychoanalytic therapy would be used to treat the client, how the client would respond to therapy, and the effectiveness of this treatment approach.
• Pharmacological approach : If treatment primarily involves the use of medications, explain which medications were used and why. Provide background on the effectiveness of these medications and how monotherapy may compare with an approach that combines medications with therapy or other treatments.

This section of a case study should also include information about the treatment goals, process, and outcomes.

When you are writing a case study, you should also include a section where you discuss the case study itself, including the strengths and limitiations of the study. You should note how the findings of your case study might support previous research. 

In your discussion section, you should also describe some of the implications of your case study. What ideas or findings might require further exploration? How might researchers go about exploring some of these questions in additional studies?

Need More Tips?

Here are a few additional pointers to keep in mind when formatting your case study:

• Never refer to the subject of your case study as "the client." Instead, use their name or a pseudonym.
• Read examples of case studies to gain an idea about the style and format.
• Remember to use APA format when citing references .

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach .  BMC Med Res Methodol . 2011;11:100.

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach . BMC Med Res Methodol . 2011 Jun 27;11:100. doi:10.1186/1471-2288-11-100

Gagnon, Yves-Chantal.  The Case Study as Research Method: A Practical Handbook . Canada, Chicago Review Press Incorporated DBA Independent Pub Group, 2010.

Yin, Robert K. Case Study Research and Applications: Design and Methods . United States, SAGE Publications, 2017.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

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CLINICAL TRIAL article

The relevance of outcome expectations in group hypnosis for stress reduction: a secondary analysis of a multicenter randomized controlled trial.

• 1 Institute of Social Medicine, Epidemiology and Health Economics, Charité – Universitätsmedizin Berlin, Berlin, Germany
• 2 Psychotherapie-Praxis Kupferstraße, Coesfeld, Germany

Background: There is evidence that patients’ positive outcome expectations prior to study interventions are associated with better treatment outcomes. Nevertheless, to date, only few studies have investigated whether individual outcome expectations affect treatment outcomes in hypnosis.

Objective: To examine whether outcome expectations to hypnosis prior to starting treatment were able to predict perceived stress, as measured on a visual analog scale (VAS), after 5 weeks.

Methods: We performed a secondary data analysis of a multicenter randomized controlled trial of intervention group participants only. Study participants with stress symptoms were randomized to 5 weekly sessions of a group hypnosis program for stress reduction and improved stress coping, plus 5 hypnosis audio recordings for further individual practice at home, as well as an educational booklet on coping with stress. Perceived stress for the following week was measured at baseline and after 5 weeks using a visual analog scale (0–100 mm; VAS). Hypnosis outcome expectations were assessed at baseline only with the Expectations for Treatment Scale (ETS). Unadjusted and adjusted linear regressions were performed to examine the association between baseline expectations and perceived stress at 5 weeks.

Results: Data from 47 participants (M = 45.02, SD = 13.40 years; 85.1% female) were analyzed. Unadjusted (B = 0.326, t  = 0.239, p  = 0.812, R 2  = 0.001) and adjusted (B = 0.639, t  = 0.470, p  = 0.641, R 2  = 0.168) linear regressions found that outcome expectations to hypnosis were not associated with a change in perceived stress between baseline and after 5 weeks in the intervention group.

Conclusion: Our findings suggest that the beneficial effect of group hypnosis in distressed participants were not associated with outcome expectations. Other mechanisms of action may be more important for the effect of hypnosis, which should be explored in future research.

Clinical trial registration : ClinicalTrials.gov , identifier NCT03525093.

The European Agreement on Work-Related Stress defines stress as a state characterized by physical, psychological, or social complaints or dysfunctions resulting from individuals feeling unable to meet the demands or expectations placed upon them ( Broughton, 2004 ). This definition underscores the global recognition of health-related problems associated with stress ( Fisch et al., 2020a ; Gnall et al., 2023 ; Mazure et al., 2023 ; Popescu et al., 2023 ; Sara et al., 2023 ; Walther and Wirtz, 2023 ). In Germany, a survey of 1,200 adults found that 61% reported experiencing stress either frequently or occasionally ( Wohlers and Hombrecher, 2016 ).

Hypnosis is a state of focused attention and heightened suggestibility that can be induced by a trained professional. It has been used as a therapeutic tool for a variety of clinical purposes, including stress reduction. A 2017 systematic review examined the effects of hypnosis in patients with perceived stress. While six of the nine included studies reported significant positive effects of hypnosis on stress reduction, all of the included studies had a high risk of bias and used exploratory designs ( Fisch et al., 2017 ). Since the publication of the aforementioned review, our research group has conducted a multicenter randomized controlled trial offering group hypnosis for stress reduction and improved stress coping, which showed a reduction in perceived stress in the hypnosis group compared to the control group at both 5 and 12 weeks ( Fisch et al., 2020a ). Other studies have also shown that hypnosis leads to a lower perception of stress ( Payrau et al., 2017 ; Olendzki et al., 2020 ; Slonena and Elkins, 2021 ; Vahdat et al., 2022 ).

Although scientific evidence from other fields suggests that expectations are able to positively influence treatment outcomes for a range of medical conditions and procedures ( Mondloch et al., 2001 ; Constantino et al., 2011 ; Auer et al., 2016 ), little research has examined whether expectations to hypnosis might be able to predict treatment outcomes.

Patients’ expectations may encompass their beliefs about the efficacy of hypnosis and their anticipated outcomes from the treatment in question. To date, few studies have attempted to discern whether individuals with high expectations of positive outcomes to hypnosis will experience more significant benefits compared to those with low expectations ( Sliwinski and Elkins, 2017 ; De Pascalis et al., 2021 ; Egli et al., 2022 ). This debate is imperative because it raises questions about the role of psychological factors in the therapeutic process and the validity of hypnosis as a treatment modality in its own right. A perspective that has not been very well researched suggests that patients with different expectations to hypnosis may experience a different therapeutic effect, whereby their belief in the efficacy of the treatment may influence their response to it ( Frisaldi et al., 2015 ; Koban et al., 2017 ). In this respect, participants’ expectations may confound the interpretation of study results, making it challenging to isolate the specific effects of hypnosis itself. As indicated by other studies, expectations also contribute to placebo and nocebo effects ( Petrovic et al., 2005 ; Wager et al., 2007 ; Tracey, 2010 ). Consequently, they could also influence the effectiveness of hypnotic interventions ( Kirsch, 1985 ). Moreover, it is assumed that hypnosis in clinical practice can induce altered states of consciousness independently of initial expectations and produce therapeutic benefits through suggestion and relaxation techniques.

We performed a secondary data analysis to examine whether treatment expectations to a group hypnosis program for stress reduction and improved stress coping would be able to predict perceived stress in the previous week, as measured on a visual analog scale, after 5 weeks.

Study design

This study comprised a secondary analysis of the two-armed randomized, controlled, open, multicenter HypnoStress trial (Trial Registration No. NCT03525093; Ethical Approval No. EA1/067/18). Details of the original study have been published elsewhere ( Fisch et al., 2020a ). This paper reports findings from a secondary data analysis only and required no additional ethical approval.

Participants and recruitment

Individuals were considered eligible for participation in the original trial if they were aged between 18 to 70 years, reported a subjective stress level of 40 mm or higher on a visual analog scale (VAS) for the preceding week (measured on a scale of 0 to 100 mm), reported a perceived increase in stress lasting for at least 3 months, maintained overall good health, and provided written informed consent. Conversely, individuals were excluded if they were currently participating or planning to participate in another psychological stress reduction program within the next 12 weeks, were currently undergoing psychotherapy, had a moderate or severe acute or chronic medical condition, or had an acute or chronic mental health problem. Recruitment for the study was conducted via newspaper ads in Berlin and Coesfeld, the Charité Outpatient Department for Integrative Medicine’s website and newsletter, the psychotherapeutic clinic in Coesfeld, the Studienhospital Münster’s Newsletter, and flyers at the MEDIAN Zentrum Bad Pyrmont. Potential participants underwent a preliminary consultation with a psychologist or study physician, where they were informed about the study.

Randomization

A detailed summary of the randomization and intervention content is provided in the original article ( Fisch et al., 2020a ). Briefly, patient enrollment was conducted under the supervision of study physicians and study psychologists. Following informed consent, enrollment and baseline assessments, participants were randomized to either the intervention or control group, using a 1:1 allocation ratio via a central telephone randomization line by an independent study nurse. The randomization was stratified by study center and in blocks of 20 participants (to take into account the group size of 10 people). SAS (Version 9.4) was used to generate the random allocation sequence.

Study intervention

Both the intervention and control group received a written educational booklet on behavioral stress management provided by a German health insurance company ( Wagner-Link, 2017 ). The booklet contained sections on “recognizing stress,” “managing stress,” and “preventing stress.” The “recognizing stress” section outlined the physiological underpinnings of a natural stress response, detailing various facets of stress reactions, including cognitive, emotional, vegetative, and muscular aspects. It also aimed to sensitize readers to identify individual stressors. In the “managing stress” section, common stress management strategies such as problem-solving, time management, various relaxation techniques, sports, and recognizing and modifying unfavorable attitudes were introduced and briefly discussed. The third section, “preventing stress,” introduced the salutogenesis model and provided insights into the structure and promotion of resilience factors, with a particular emphasis on maintaining social connections. Additionally, this section outlined short-term stress management strategies and offers a suggested training protocol ( Wagner-Link, 2017 ; Fisch et al., 2020b ).

In addition to this, the intervention group received a hypnosis group program, which was previously designed, refined and tested in a feasibility study ( Fisch et al., 2020b ). The primary objectives of the hypnosis group program were to induce relaxation, assist participants in recognizing, activating, and experiencing resources for coping with stressful situations, foster the development and refinement of stress-coping skills, and impart mental training and anchoring techniques. The program was delivered by certified hypnotherapists (two psychotherapists and one family physician) and consisted of five standardized sessions of health education, hypnotic inductions, and therapeutic discussions. Hypnosis sessions were conducted weekly with groups of 8 to 12 participants and lasted 120 min. Additionally, at the end of each session, participants were provided with pre-recorded audio recordings (available as either CDs or downloadable MP3 files) of the hypnosis exercises so that they could self-practice at their convenience and discretion. Control group participants were offered free participation in the hypnosis group program following study completion.

Outcome measures

Relevant outcomes for this secondary data analysis were:

Stress : perceived stress level in the previous week was measured on a visual analog scale (VAS; 0–100 mm: 0 = no stress, 100 = maximum stress) after 5 weeks.

Outcome expectations : expectations to hypnosis treatment were measured using a modified version of the Expectations for Treatment scale (ETS) ( Barth et al., 2019 ). Participants were asked to indicate their expectations to hypnosis on a Likert scale ranging from 1 (low expectations) to 4 (high expectations): “I expect that hypnosis will help me deal with stress better,” “I expect stress levels to disappear as a result of hypnosis,” “I expect my energy to improve as a result of hypnosis,” “I expect my physical performance to improve as a result of hypnosis,” “I expect that after the hypnosis stress levels will improve significantly.” Items were summed to create a total score, with a minimum score of 4 indicating low expectations and a maximum score of 20 indicating high expectations.

Demographic variables : self-reported data on age, gender, education, employment status, health parameters and stress factors were obtained at baseline.

Statistical analysis

The ETS was collapsed into a dichotomous variable using the median value ( MD  = 13.00) as the cut-off to group individuals into high (if the median score was above MD  = 14.00) and low (if the median score was below MD  = 13.00) expectations in order to determine and display baseline group differences regarding expectations to hypnosis only. Baseline group differences for sociodemographic, health and stress-related characteristics were analyzed using t-tests for continuous data and chi-square tests or Fisher’s exact test for small cell counts for categorical data, and summarized using means, SDs, or percentages.

Unadjusted linear regressions were then calculated to examine whether expectations to hypnosis (for this the ETS sum score was used) in the intervention group would be able to predict change in perceived stress between baseline and after 5 weeks as measured on a VAS. Linear regressions were subsequently adjusted for any potential confounders (baseline stress, study center, age, and sex). To determine whether expectations to hypnosis (for this the ETS sum score was used) in the intervention group would be able to predict change in perceived stress between baseline and after 5 weeks, we performed a sensitivity analysis using Spearman’s rho correlation to examine whether this non-parametric alternative would yield similar results as the linear regression. All results were considered exploratory. Analyses were conducted using the IBM Statistical Package for Social Sciences (SPSS), Version 28.

Sensitivity analysis

Two sensitivity analyses were conducted to test the robustness of our results. For the first we performed a non-parametric correlation analysis using Spearman’s rank-order correlation to determine expectations to hypnosis and change in perceived stress between baseline and after 5 weeks. For the second we performed unadjusted and adjusted regression analyses using the change in Cohen’s Perceived Stress Scale (CPSS) ( Cohen et al., 1983 ) score as an outcome.

Detailed sociodemographic characteristics of the sample are outlined in the original study article ( Fisch et al., 2020a ). Table 1 shows the comparison of sociodemographic characteristics between those with high and low expectations to hypnosis in the intervention group. We observed no relevant differences at baseline in individuals with high and low expectations.

Table 1 . Comparison of sociodemographic characteristics between those with low versus high expectations in the intervention group (baseline).

Unadjusted linear regressions showed that expectations to hypnosis were not associated with a change in perceived stress between baseline and after 5 weeks ( B  = 0.326, t  = 0.239, p  = 0.812, R 2  = 0.001) ( Figure 1 ).

Figure 1 . Expectations to hypnosis and perceived stress after 5 weeks in the intervention group.

Similarly, adjusted linear regressions showed that expectations to hypnosis were not associated with a change in perceived stress between baseline and after 5 weeks (B = 0.639, t  = 0.470, p  = 0.641, R 2  = 0.168) ( Figure 2 ).

Figure 2 . Expectations to hypnosis and perceived stress after 5 weeks in the intervention group; adjusted for respective baseline value, study center, age and sex.

Sensitivity analysis using Spearman’s rank-order correlation indicated no relevant relationship between expectations to hypnosis and change in perceived stress between baseline and after 5 weeks (r s  = 0.06, p  = 0.703).

Similar to our other findings unadjusted (B = −0.350, t  = −0.870, p  = 0.389, R 2  = 0.018) and adjusted (B = −0.118, t  = −0.341, p  = 0.735, R 2  = 0.400) linear regressions found that outcome expectations to hypnosis were not associated with a change in perceived stress between baseline and after 5 weeks in the intervention group on the CPSS.

Contrary to previous research that has shown that expectations predict treatment outcomes (e.g., Auer et al., 2016 ), our findings showed no association between participants’ expectations and perceived stress after 5 weeks. Consequently, other contextual factors, such as hypnotic relaxation, active resource activation, and reframing techniques and group interactions may have played a greater role than expectations in determining treatment outcomes.

Our results showed that overall participants had relatively high expectations at baseline (M = 13.74, SD = 2.72) before being randomized to and participating in the group hypnosis program. Therefore, it could be suggested that future studies should include individuals with more diverse expectations in order to determine how these may be associated with varying treatment outcomes. For example, research on recovery expectations in patients with back pain ( Kamper et al., 2015 ) has shown that the level of expectations may indeed predict treatment outcomes, with high expectations leading to the greatest improvement compared to moderate and low expectations. Further to this, participants’ baseline level of stress was relatively high in our study. However, future research which includes individuals with low, moderate, and severe levels of stress is necessary to determine the interplay between a diverse range of expectations and the outcome under investigation.

Information on patients’ expectations was only collected at baseline. As a result, we do not know whether expectations changed over the course of the group program. Yet, it has been proposed that patient expectations to treatment should be assessed before, during and after treatment as expectations may change over the course of treatment ( Kamper et al., 2015 ; Laferton et al., 2017 ).

In addition, we did not assess whether trial participants had previously undergone hypnosis. Nevertheless, it may be important to ascertain this, as expectations may be influenced by previous exposure to hypnosis. For example, research has shown that individuals who had previously received acupuncture prior to participating in a trial investigating different briefing contents before a minimal acupuncture treatment in patients with chronic low back pain had higher expectations than those who had never received acupuncture. However, the study authors caution that higher expectations cannot be explained solely by patients’ previous experience with acupuncture, but that the relative contribution of contextual factors on patients’ pre-treatment expectations should also be considered ( Zieger et al., 2022 ).

Although the ETS has shown to be a valid and reliable scale for measuring outcome expectations, it was originally developed in the context of acupuncture ( Barth et al., 2019 ). While the scale has been used to determine outcome expectations across a variety of studies, there has been mixed evidence as to whether expectations predict therapeutic outcomes ( de Matos et al., 2020 ; Barth et al., 2021 ; Egli et al., 2022 ; Zieger et al., 2022 ; Müller-Schrader et al., 2023 ). Further research should therefore be conducted using different treatment outcomes and patient populations to further explore to what extent the original scale and any modified versions are indeed able to accurately predict outcome expectations. Furthermore, the scale is not based on any theoretical models and only examines positive outcome expectations. Nonetheless, this may be problematic, as the absence of theory and negative outcome expectations could lead to important constructs being missed, thus limiting researchers’ ability to determine whether expectations do indeed predict treatment outcomes.

Lastly, we did not explore the potential influence of other variables, such as trust in the therapist. These factors may interact with expectations in complex ways that were not addressed in our research.

To our knowledge this is the first study that has explored the predictive value of expectations on hypnosis for stress reduction. It contributes to the growing understanding of the relationship between patient expectations and treatment outcomes in general, but more specifically in the field of hypnotherapy. In addition, it is based on a randomized controlled multicenter trial with high adherence rates and whose intervention was thoroughly designed and delivered by qualified hypnotherapists (physicians or psychological psychotherapists). We also recognize that the small number of study participants is a clear limitation of this secondary analysis, which may affect the generalizability of our findings. Furthermore, we did not originally plan to perform any further analysis, and therefore the results can only be interpreted in an exploratory manner.

In this analysis, we found no association between participants’ expectations and perceived stress at 5 weeks in the intervention group. Our results suggest that factors contributing to the effect of hypnotherapy may have acted independently of participants’ expectations. Further research is required to explore the complex relationship between pre-therapy expectations and hypnotherapy outcomes.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving humans were approved by Ethical Approval No. EA1/067/18; Ethics Committee of the Charité – Universitätsmedizin Berlin; Charité Mitte, Charitéplatz 1 (local address: Virchowweg 10) 10117 Berlin. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

JS: Writing – original draft, Writing – review & editing. MT: Conceptualization, Funding acquisition, Investigation, Project administration, Supervision, Writing – review & editing. BB: Conceptualization, Project administration, Supervision, Writing – review & editing. SF: Conceptualization, Funding acquisition, Investigation, Writing – review & editing. SK: Methodology, Software, Writing – original draft, Writing – review & editing.

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This study was an investigator-initiated study. A small funding support for the original study was received by a Crowdfunding Campaign ( https://www.betterplace.org/de/projects/55653?utm_campaign=ShortURLs&utm_medium=project_55653&utm_source=PlainShortURL ). The people funding the study and also the crowdfunding platform had no influence on the design and methodology of the study, the data collection, analysis or interpretation, or the preparation of the manuscript.

Acknowledgments

We would like to thank all study patients, the whole study team, especially our study nurse Margit Cree for their outstanding work on this study.

Conflict of interest

MT and SF are both members of the Deutsche Gesellschaft für Hypnose und Hypnotherapy (DGH) and certified hypnotherapists who have received payments for teaching hypnosis within the hypnotherapy training programs of the DGH in the past.

The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Abbreviations

DGH, Deutsche Gesellschaft für Hypnose und Hypnotherapy; ETS, Expectations for Treatment scale; MD, median value; SPSS, Statistical Package for Social Sciences; VAS, visual analogue scale.

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Keywords: hypnosis, hypnotherapy, stress, stress reduction, outcome expectation, randomized controlled trial

Citation: Siewert J, Teut M, Brinkhaus B, Fisch S and Kummer S (2024) The relevance of outcome expectations in group hypnosis for stress reduction: a secondary analysis of a multicenter randomized controlled trial. Front. Psychol . 15:1363037. doi: 10.3389/fpsyg.2024.1363037

Received: 29 December 2023; Accepted: 09 April 2024; Published: 19 April 2024.

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Copyright © 2024 Siewert, Teut, Brinkhaus, Fisch and Kummer. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Julia Siewert, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Less is known about complex posttraumatic stress disorder (CPTSD) than postrraumatic stress disorder (PTSD) in military veterans, yet this population may be at greater risk of the former diagnosis. Executive function impairment has been linked to PTSD treatment outcomes. The current study therefore aimed to explore possible associations between each CPTSD symptom cluster and executive function to understand if similar treatment trajectories might be observed with the disorder.

A total of 428 veterans from a national charity responded to a self-report questionnaire which measured CPTSD symptom clusters using the International Trauma Questionnaire, and executive function using the Adult Executive Function Inventory. Single and multiple linear regression models were used to analyse the relationship between CPTSD symptom clusters and executive function, including working memory and inhibition.

Each CPTSD symptom cluster was significantly associated with higher executive function impairment, even after controlling for possible mental health confounding variables. Emotion dysregulation was the CPTSD symptom cluster most strongly associated with executive function impairment.

Conclusions

This is the first study to explore the relationship between executive function and CPTSD symptom clusters. The study builds on previous findings and suggests that executive function could be relevant to CPTSD treatment trajectories, as is the case with PTSD alone. Future research should further explore such clinical implications.

Peer Review reports

Military veterans face a greater risk of experiencing PTSD than the general UK population [ 1 ] and are more likely to meet criteria for Complex PTSD (CPTSD) than PTSD [ 2 ]. PTSD encompasses a set of symptoms which may be experienced following a traumatic event, including hyperarousal, re-experiencing (nightmares, intrusions), cognitive and behavioural avoidance and negative alterations in mood (DSM-V; [ 3 ]). CPTSD was added to the International Classification of Diseases in 2011 [ 4 ] as a distinct disorder. A diagnosis of CPTSD includes experiencing clusters of symptoms that encompass PTSD, as well as symptom clusters referred to as Disturbances in Self-Organisation (DSO), which are: emotion dysregulation, interpersonal difficulties, and negative self-concept, as well as functional impairment connected to both PTSD and DSO symptoms.

CPTSD has been linked with sustained and multiple traumas [ 5 ] as well as interpersonal trauma [ 6 ]. Military veterans appear to be at greater risk of CPTSD than PTSD [ 7 ]. Indeed, CPTSD appears to be more prevalent in UK treatment-seeking veterans than PTSD (with 80% meeting criteria for CPTSD compared to 20% for PTSD; [ 2 , 8 ]. Additionally, proportionally higher treatment dropout rates are reported for veterans with CPTSD [ 9 ]. It is therefore clinically important to understand factors which may be relevant to both PTSD and CPTSD, as interventions may need to be tailored to each disorder respectively.

PTSD and executive function

An association between impairments in executive function (EF), and posttraumatic stress disorder (PTSD) is well-established in the literature (for review see: [ 10 , 11 , 12 ]). EFs are a collection of abilities grouped together for their relevance to planning and executing complex, goal-directed behaviour [ 13 , 14 , 15 ]. There is significant variation in both definitions of the concept and how the construct is operationalised, although the current study follows Miyake and colleagues [ 16 ] as this conceptualisation aligns well with the self-report measure of executive function used in this study. These authors identify cognitive flexibility, working memory and inhibition as core EFs, deficits in all of which may be relevant to PTSD [ 17 , 18 , 19 , 20 , 21 ]. Furthermore, one study has reported that greater inhibitory control is associated with a better improvement in PTSD symptoms following psychological treatment, indicating the possible relevance of EF in PTSD recovery trajectories [ 22 ]. Less is known about whether similar trajectories would be observed in those with CPTSD. However, insight may be drawn from neurocognitive explanations of the observed associations between EF and PTSD.

Neurocognitive models of PTSD and EF

Several meta-analyses of lesion and neuroimaging studies implicate the prefrontal cortex (PFC) as key in supporting EF [ 23 , 24 , 25 ]. The PFC has been theorised as a control centre, mediating between sensory inputs and behavioural outputs via regulation of brain systems central to emotion processing such as the amygdala [ 26 ]. The PFC is also structurally associated with PTSD, as well as the amygdala, hippocampus, and cingulate cortex [ 27 ], with this system key to attaching emotional valence to memories relevant to the fear-based experiences that lead to PTSD [ 19 ].

The shared relevance of these brain systems to both EF and PTSD suggests a neurocognitive explanation for the overlap observed between the two constructs. For example, one neurocognitive model of PTSD posits that PFC (and associated deficits in EF) may be ineffectively regulating hyperarousal of the amygdala in individuals with PTSD when a perceive threat is observed in a safe environment [ 28 , 29 , 30 ]. Furthermore, elevated arousal – a symptom of PTSD – may deplete cognitive resources leading to deficits in EF as attention is focused instead on regulating hyperarousal [ 20 , 31 , 32 , 33 ].

EFs and CPTSD

Neuroimaging studies reinforce this theory and suggest functional connectivity between the PFC and brain regions relevant to emotion regulation are key to supporting EF [ 34 , 35 ]. Emotion dysregulation therefore may be pertinent to the observed overlap between PTSD and EF. Given emotion dysregulation is a DSO symptom of CPTSD, exploring associations between CPTSD and EFs could inform understanding of the disorder and how existing PTSD interventions could be tailored to improve treatment response in veterans seeking treatment for CPTSD. In a study using an adolescent sample, deficits in EFs were associated with greater CPTSD severity [ 36 ]. However, less is known about the relationship between CPTSD and EFs in veteran populations.

The current study

Given the potential relevance of EF to PTSD treatment outcomes in veterans, and the need to further understand CPTSD in this population, the current study explores the relationship between both PTSD and CPTSD and a self-report measure of EF (inhibition and working memory) in a clinical sample of UK veterans. Associations between each PTSD symptom cluster and EFs are separately investigated, including the DSO clusters that encompass CPTSD. In line with previous studies [ 36 ], it is hypothesised that lower executive functioning scores (both working memory and inhibition) will be associated with greater severity of CPTSD symptoms.

This study was approved by [blinded for review].

Participants

Of the veterans seeking treatment UK charity, a 20% random sample was selected to assess whether they met study inclusion criteria: (1) having a valid email address; (2) having provided consent to contact from the research team about studies; (3) had attended one or more appointments (classed as treatment-seeking). In total 989 veterans were emailed with the study link, to which 428/989 responded (43.3% response rate; M age =50.4, SD age =10.9). Participation was voluntary. No differences were found between those who returned completed questionnaires and non-responders [ 2 ]. We determined this by analysing predictors of returning a completed survey, including age, sex and service branch.

Eligible and consenting veterans were emailed the link to a self-report questionnaire hosted on Survey Monkey, which included demographic questions and the measures described below. Responses were collected between August and October 2020 and participants were emailed not more than five times. The questionnaire took approximately 20 min to complete. Full study procedure has been described previously [ 2 ].

The Adult Executive Function Inventory (ADEXI; [ 37 ]), measures EF on a 14-item self-report scale, with responses on a five-point Likert scale ranging from zero (definitely not true) to four (definitely true). Items 1, 2, 5, 7, 8, 9, 11, 12 and 13 comprise the working memory subscale, e.g.: “I have difficulty remembering lengthy instructions” and “when someone asks me to do several things, I sometimes only remember the first or last”. The remaining items make up the inhibition subscale, e.g.: “I have a tendency to do things without first thinking about what could happen” and “I sometimes have difficulty stopping myself from doing something that I like even though someone tells me that it is not allowed”. A higher score on the scale or each of the subscales indicates greater impairment. The ADEXI has good internal consistency and test-retest reliability, but poor convergent validity with neuropsychological tests of EF [ 37 ]. The ADEXI has good internal consistency (α = 0.68–0.72; [ 37 ]).

Symptoms of PTSD and CPTSD were measured using the International Trauma Questionnaire [ 38 ], an 18-item scale with responses on a 5-point Likert scale ranging from zero (not at all) to four (extremely). Two items measure each of the three PTSD symptom clusters: hyperarousal, re-experiencing and avoidance. Two items measure each of the three disturbances in self-organisation (DSO) symptom clusters that comprise CPTSD: negative self-concept, interpersonal relationships and affect dysregulation. Three identical items then measure functional impairment related to the PTSD and DSO symptom clusters respectively. The ITQ has strong psychometric properties [ 39 ]. Possible caseness for PTSD is indicated by a score of two or higher on at least one of each item measuring each PTSD symptom cluster, as well scoring two or higher on one of the three functional impairment items relating to PTSD symptom clusters. Possible caseness for CPTSD is indicated by meeting the criteria for PTSD, as well as scoring two or higher on at least one of the two items for each DSO symptom cluster, and at least a two on one of the functional impairment items relating to DSO symptoms. The ITQ has good internal consistency (α = 0.90; [ 39 ]).

Symptoms of generalised anxiety and depression were measured with the General Health Questionnaire (GHQ-12; [ 40 ]), a 12-item scale where a score of four or higher is indicative of potential caseness for common mental health difficulties (CMDs). The GHQ-9 has good internal consistency (α = 0.72; [ 41 ]).

Somatic symptoms were measured using the Patient Health Questionnaire (PHQ-15; [ 41 ]), a 15-item scale where a score above 15 indicates higher severity of somatic symptoms. The PHQ-15 has good internal consistency (α = 0.80; [ 42 ]).

Symptoms of poor sleep quality were measured using the Sleep Condition Indicator (SCI; [ 43 ]), an eight-item scale where a score below 16 is indicative of a potential insomnia disorder. The SCI has good internal consistency (α = 0.86; [ 44 ]).

Symptoms of difficulties with anger were measured using the Dimensions of Anger Reactions (DAR-5; [ 45 ]), a five-item scale where a score higher than 12 is indicative of possible anger difficulties. The DAR-5 has good internal consistency (α = 0.89–0.90; [ 46 ]).

Symptoms of alcohol misuse were measured using the Alcohol Use Disorders Identification Test (AUDIT; [ 47 ]), a 10-item scale where scores higher than eight and 16 respectively are classified as possible hazardous and harmful alcohol use. The AUDIT has good internal consistency (α = 0.60–0.80; [ 48 ]).

Data analysis

Data were prepared in STATA 13.0 and analysed in SPSS v.26. Continuous variables were ADEXI scores and subscale scores. These were averaged so that comparisons could be made across scores calculated from different numbers of items. All other variables were categorical, divided into case and no case or high severity and lower severity for each health outcome, and no PTSD, PTSD, and CPTSD for the ITQ variable. To understand the relationship between mental health variables, including PTSD and EF, single linear regression models were used with demographic and mental health caseness variables as predictors, and ADEXI and inhibition and working memory subscale scores as outcome variables in separate analyses. This was to understand possible confounding variables for any relationship between PTSD and CPTSD with EF. Multiple linear regression models were then used with PTSD and CPTSD caseness as predictor variables, and ADEXI score, and subscale scores as outcome variables. Those variables which were significant in the single linear regression models were included in the multiple regression models to adjust for possible confounding factors. Single linear regression models explored the relationships between individual PTSD and DSO symptom clusters with EF. ‘Caseness’ for each symptom cluster was calculated as a score of two or higher on at least one of the two items measuring each cluster. The sample met assumptions for multiple linear regression: the data were normally distributed (W = 0.96, p  = 0.23), there was low multicollinearity and there is a linear relationship between the variables used in the regression models. As described in [ 2 ], analyses were restricted to responders only and missing data were not included in the models due to the assumption that data were missing at random. A power analysis was not conducted for the present study as the analysis was exploratory and data were collected through convenience sampling [ 49 ]. In regression analysis, B values below 0.1. between 0.1 and 0.5 and above 0.5 are broadly considered small, medium and high respectively [ 50 ].

Demographic characteristics are described in Table  1 , as well as descriptive statistics for the variables included in regression models.

Single regression models

Single linear regression models for demographic and mental health factors are presented in Table  2 . Being unemployed and having an ethnicity other than white were significantly associated with higher overall EF, inhibition and working memory impairment. Having high somatic symptoms and meeting caseness for probable common mental health difficulties were also associated with higher overall EF, inhibition and working memory impairment. In addition, scores indicating hazardous alcohol use were associated with working memory and inhibition impairment, and sleep disturbances were associated with a higher working memory impairment.

Multiple regression models

Multiple regression models for PTSD adjusted for all other significant variables besides CPTSD caseness observed in the single regression models. The same models were analysed including CPTSD as a predictor and not PTSD caseness. These models are displayed in Table  3 . Across all adjusted models, both PTSD and CPTSD remained significant predictors for EF, inhibition and working memory.

PTSD and DSO symptom clusters

Linear regression models for each of the PTSD and DSO symptom clusters and EF, inhibition and working memory are displayed in Table  4 . In line with our hypothesis, each symptom cluster was significantly associated with EF, as well as inhibition and working memory subscales.

The aim of the current study was to explore the associations between CPTSD symptom clusters and EF in a clinical sample of UK veterans. Both PTSD and CPTSD caseness were significantly associated with greater impairment in inhibition and working memory, in line with our hypothesis. All PTSD symptom clusters, and the DSO symptom clusters which encompass CPTSD, were associated with inhibition and working memory. In particular, the DSO symptom emotion dysregulation was most strongly associated with EF impairment. PTSD encompasses symptoms hyperarousal, re-experiencing and avoidance. CPTSD is a relatively new separate diagnosis which includes PTSD symptoms as well as DSO symptoms: emotion dysregulation, negative self-concept and interpersonal difficulties, as well as functional impairment relating to these domains [ 4 ].

These associations remained after controlling for the following possible confounders, which were also found to be associated with greater EF impairment: employment status, ethnicity, somatisation severity, common mental health disorders, alcohol misuse and for working memory, sleep function. The finding that EF impairment is associated with worse health coheres with previous research, which has observed relationships between EF deficits and both depression [ 51 ] and somatisation disorder [ 52 ]. Additionally, sleep deprivation is consistently associated with impairments in working memory [ 53 , 54 ].

Emotion dysregulation and EF impairment

Our finding that emotion dysregulation was the CPTSD symptom cluster most associated with EF coheres with and builds on neurocognitive models espoused in the literature. Previous research has suggested functional connectivity between the PFC and limbic system is key in the overlap observed between PTSD chronicity, severity, and EF impairment [ 10 , 55 ]. In one study, those with greater functional connectivity in this system - termed the frontal parietal control and limbic network (FPCN) - were observed to have less chronicity of and greater reduction in PTSD symptoms [ 56 ]. The FPCN underlies emotion processing [ 57 ], mind wandering [ 58 ] and is neurally connected with the default mode network (DMN; [ 59 ]), all of which are associated with PTSD [ 60 ]. Moreover, the development of the DMN is particularly sensitive during childhood, with research suggesting its development could be affected by early and prolonged trauma [ 61 , 62 ]. Given these factors are more strongly associated with CPTSD than PTSD [ 5 ], the finding that DSO symptom cluster emotion dysregulation was most related to EF suggests similar neurobiological mechanisms may be involved in CPTSD as those espoused for the overlap between EF and PTSD.

Limitations

A number of limitations to the present study should be noted. Firstly, whilst the self-report measure of EF facilitated the collection of data from a larger sample, it has limited convergent validity with neuropsychological measures of EF [ 37 ]. However, as a self-report measure, the scale has strong psychometric properties [ 37 ] and self-report EF measures are strongly related to functional impairment [ 63 ]. Secondly, the scale does not include items measuring cognitive flexibility, although this would be difficult to capture on a self-report measure. Data were collected during the Covid-19 pandemic, and environmental factors related to restrictive measures at the time could have affected participants’ responses. However, our research suggests veterans’ mental health difficulties remained relatively stable throughout the pandemic. Finally, no causal relationships can be interpreted from the current findings due to the cross-sectional design of the study. However, the observed finding of an association between DSO symptom clusters and EF impairment builds on previous findings of similar association with PTSD clusters and this can inform future research and clinical studies.

Implications for treatment

Taken together, the findings of the present study suggest that CPTSD interventions may – as observed with PTSD treatment outcomes [ 22 ] – result in better symptom improvement in patients who display greater inhibitory control in neuropsychological tests. By separately analysing both PTSD and DSO symptom clusters, the current study has highlighted the potential role of emotion dysregulation in the overlap between EF impairment and PTSD observed in previous studies [ 10 , 11 , 12 ]. Future research might explore whether veterans with better inhibitory control and working memory respond better to CPTSD interventions. For example, Enhanced Skills Training in Affective and Interpersonal Regulation (ESTAIR; [ 64 ]) is a modular CPTSD treatment which sequentially targets each DSO symptom – including emotion dysregulation. Future studies might explore whether building skills in emotion regulation reduces impairment in EF and subsequently improves recovery trajectories.

This was the first study to explore the relationship between EF and CPTSD symptom clusters in a clinical sample of UK Armed Forces veterans. That DSO symptom clusters, in addition to PTSD clusters, were associated with EF builds on previous findings and suggests that CPTSD treatment outcomes could similarly be affected by levels of EF impairment in veteran patients. Future research should explore the clinical implications of these findings further.

Data availability

The datasets analysed during the current study are not publicly available due to patient confidentiality.

Abbreviations

Complex posttraumatic stress disorder

Default mode network

Disturbances in self-organisation

• Executive function

Posttraumatic stress disorder

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DM conceptualised the study and prepared the data. NB analysed the data and drafted the manuscript. EN drafted the manuscript. All authors contributed to manuscript revision.

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Correspondence to Natasha Biscoe .

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Biscoe, N., New, E. & Murphy, D. Complex PTSD symptom clusters and executive function in UK Armed Forces veterans: a cross-sectional study. BMC Psychol 12 , 209 (2024). https://doi.org/10.1186/s40359-024-01713-w

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Received : 23 October 2023

Accepted : 05 April 2024

Published : 15 April 2024

DOI : https://doi.org/10.1186/s40359-024-01713-w

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